national guidelines for seniors’ mental health · the national guidelines for seniors’ mental...

NATIONAL GUIDELINESFOR SENIORS’ MENTAL HEALTH

(Focus on Mood and Behaviour Symptoms)

The Assessment and Treatmentof Mental Health Issues in

Long Term Care Homes

MAY 2006

CANADIAN COALITION FOR SENIORS’ MENTAL HEALTHCOALITION CANADIENNE POUR LA SANTÉ MENTALE DES PERSONNES ÂGÉES

The Assessment and Treatmentof Mental Health Issues in

Long Term Care Homes(Focus on Mood and Behaviour Symptoms)

The CCSMH gratefully acknowledges support from:POPULATION HEALTH FUND, PUBLIC HEALTH AGENCY OF CANADA*

*The opinions expressed in this publication are those of the authors/researchers and do not necessarily reflectthe official views of the Public Health Agency of Canada

The CCSMH gratefully acknowledges support from AIRD & BERLIS LLP for their guidance on Copyright issuesand for the review and creation of the disclaimer statement.

The CCSMH gratefully acknowledges unrestricted educational grant support for the dissemination ofthe National Guidelines for Seniors’ Mental Health from:

Disclaimer: This publication is intended for information purposes only, and is not intended to be interpreted or used as astandard of medical practice. Best efforts were used to ensure that the information in this publication is accurate, however thepublisher and every person involved in the creation of this publication disclaim any warranty as to the accuracy, complete-ness or currency of the contents of this publication. This publication is distributed with the understanding that neither thepublisher nor any person involved in the creation of this publication is rendering professional advice. Physicians and otherreaders must determine the appropriate clinical care for each individual patient on the basis of all the clinical data availablefor the individual case. The publisher and every person involved in the creation of this publication disclaim any liability aris-ing from contract, negligence, or any other cause of action, to any party, for the publication contents or any consequences aris-ing from its use.

© Canadian Coalition for Seniors’ Mental Health, 2006

Canadian Coalition for Seniors’ Mental Healthc/o Baycrest

3560 Bathurst Street, Rm. 311 West Wing – Old Hosp.Toronto, ON

M6A 2E1phone: (416) 785-2500 ext 6331

fax: (416) [email protected]

www.ccsmh.ca

AstraZeneca Canada Inc.

Eli Lilly and Company

Janssen-Ortho Inc.

Organon Canada Ltd

RBC Foundation

Canadian Institutes for Health Research -Institute of Aging

Foreword

About the Canadian Coalition for Seniors’ Mental Health

The Canadian Coalition for Seniors’ Mental Health (CCSMH) was established in 2002 fol-lowing a two-day symposium on “Gaps in Mental Health Services for Seniors’ in Long-TermCare Settings” hosted by the Canadian Academy of Geriatric Psychiatry (CAGP). In 2002,Dr. David Conn and Dr. Ken Le Clair (CCSMH co-chairs) took on leadership responsibili-ties for partnering with key national organizations, creating a mission and establishinggoals for the organization. The mission of the CCSMH is to promote the mental health ofseniors by connecting people, ideas, and resources.

The CCSMH has a volunteer Steering Committee that provides ongoing strategic advice,leadership and direction. In addition, the CCSMH is composed of organizations and indi-viduals representing seniors, family members and caregivers, health care professionals,frontline workers, researchers, and policy makers. There are currently over 750 individualmembers and 85 organizational members from across Canada. These stakeholders are rep-resentatives of local, provincial, territorial and federal organizations.

Aim of Guidelines

Clinical practice guidelines are defined as “systematically developed statements of recom-mendation for patient management to assist practitioner and patient decisions aboutappropriate health care for specific situations” (Lohr & Field, 1992).

The CCSMH is proud to have been able to facilitate the development of these clinical guide-lines. These are the first interdisciplinary, national best practices guidelines to specificallyaddress key areas in seniors’ mental health. These guidelines were written by and for inter-disciplinary teams of health care professionals from across Canada.

The aim of these guidelines is to improve the assessment, treatment, management and pre-vention of key mental health issues for seniors, through the provision of evidence-basedrecommendations. The recommendations given in these guidelines are based on the bestavailable evidence at the time of publication and when necessary, supplemented by theconsensus opinion of the guideline development group.

Funding for the CCSMH Guideline Initiative was provid-ed by the Public Health Agency of Canada, PopulationHealth Fund. The CCSMH gratefully acknowledges thePublic Health Agency of Canada for its ongoing supportand continued commitment to the area of seniors’ men-tal health.

In addition, special thanks to the Co-leads and GuidelineDevelopment Group members who dedicated countlessnumber of hours and engaged in the creation of theguidelines and recommendations. Your energy, enthusi-asm, insight, knowledge, and commitment were trulyremarkable and inspiring.

The CCSMH would like to thank all those who partici-pated in the guideline workshops at the National BestPractices Conference: Focus on Seniors’ Mental Health 2005(Ottawa, September 2005) for their feedback andadvice.

We would also like to thank Mr. Howard Winkler andAird & Berlis LLP for their in-kind support in reviewingthe guideline documents and providing legal perspectiveand advice to the CCSMH.

Finally, the CCSMH would like to acknowledge the con-tinued dedication of its Steering Committee members.

CCSMH Guideline Project Steering Committee

Chair ....................................................................................................................................................................Dr. David Conn

Project Director...................................................................................................................................................Ms. Faith Malach

Project Manager ....................................................................................................................................Ms. Jennifer Mokry

Project Assistant ................................................................................................................................Ms. Kimberley Wilson

Co-Lead, The Assessment and Treatment of Mental Health Issues in LTC Homes.................................................Dr. David Conn

Co-Lead, The Assessment and Treatment of Mental Health Issues in LTC Homes .........................................Dr. Maggie Gibson

Co-Lead, The Assessment and Treatment of Delirium .........................................................................................Dr. David Hogan

Co-Lead, The Assessment and Treatment of Delirium........................................................................................Dr. Laura McCabe

Co-Lead, The Assessment and Treatment of Depression .................................................................................Dr. Diane Buchanan

Co-Lead, The Assessment and Treatment of Depression ...........................................................Dr. Marie-France Tourigny-Rivard

Co-Lead, The Assessment of Suicide Risk and Prevention of Suicide .....................................................................Dr. Adrian Grek

Co-Lead, The Assessment of Suicide Risk and Prevention of Suicide..................................................................Dr. Marnin Heisel

Co-Lead, The Assessment of Suicide Risk and Prevention of Suicide .................................................................Dr. Sharon Moore

CCSMH Steering Committee

Canadian Academy of Geriatric Psychiatry ...................................................................................Dr. David Conn (co-chair)

Canadian Academy of Geriatric Psychiatry ...................................................................................Dr. Ken Le Clair (co-chair)

Alzheimer Society of Canada...................................................................................................................Mr. Stephen Rudin

CARP Canada’s Association for the Fifty Plus .......................................................................................................Ms. Judy Cutler

Canadian Association of Social Workers ...........................................................................................Ms. Marlene Chatterson

Canadian Caregiver Coalition..................................................................................................................Ms. Esther Roberts

Canadian Geriatrics Society................................................................................................................................Dr. David Hogan

Canadian Healthcare Association...............................................................................................................Mr. Allan Bradley

Canadian Mental Health Association ................................................................................................Ms. Kathryn Youngblut

Canadian Nurses Association ............................................................................................................................Dr. Sharon Moore

Canadian Psychological Association ............................................................................Dr. Maggie Gibson / Dr. Venera Bruto

Canadian Society of Consulting Pharmacists ...........................................................................Dr. Norine Graham Robinson

College of Family Physicians of Canada .........................................................................................................Dr. Chris Frank

Public Health Agency of Canada – advisory...............................................................Dr. Louise Plouffe/ Ms. Simone Powell

Executive Director .....................................................................................................................................Ms. Faith Malach

Acknowledgements

Dr. Sid Feldman, M.D., C.C.F.P., F.C.F.P.Group MemberChief, Department of Family and CommunityMedicine, Baycrest Geriatric Health Care System;Assistant Professor and Director, Care of the ElderlyProgram, Department of Family and CommunityMedicine, University of Toronto, Toronto, Ontario

Dr. Sandi Hirst, RN, BScN, MSc(Ned), PhD, GNCIGroup MemberAssociate Professor, Faculty of Nursing,University of Calgary, Calgary Alberta

Sandra Leung, BscPharmacy, FASCPGroup MemberClinical Pharmacist, Behavioral Stabilization Unitand Mental Health Unit, Capital Care Lynnwood,Edmonton, Alberta; Consultant Pharmacist,Community Care Services-Continuing CareServices, Capital Health, Edmonton, Alberta

Dr. Penny MacCourt, MSW, PhDGroup MemberPost Doctoral Fellow, Centre on Aging,University of Victoria, Victoria, British Columbia

Faith Malach, MHSc, MSW, RSWProject DirectorExecutive Director, Canadian Coalition for Seniors’Mental Health; Adjunct Practice Professor,Faculty of Social Work, University of Toronto,Toronto, Ontario

Dr. Kathy McGilton, BScN, MSc, PhDGroup MemberScientist, Toronto Rehabilitation Institute; AffiliateScientist, Kunin-Lunenfeld Applied Research Unit,Baycrest; Assistant Professor & Co-investigatorNursing Effectiveness, Utilization & OutcomesResearch Unit, Faculty of Nursing,University of Toronto, Toronto, Ontario

Ljiljana Mihic, M.A., Ph.D. CandidateGroup MemberPh. D. Candidate, Department of Psychology,The University of Western Ontario,London, Ontario

Jennifer Mokry, MSW, RSWProject CoordinatorProject Manager, Canadian Coalition for Seniors’Mental Health, Toronto, Ontario

Karen Cory, Hons. B.Sc., M.L.I.SConsultantMedical Librarian, Library Services, Staff Library,St. Joseph’s Health Care, London, ParkwoodHospital, London, Ontario

Dr. Ken Le Clair, MD, FRCPCConsultantProfessor and Chair, Geriatric Division,Department of Psychiatry, Queen’s University;Clinical Director, Specialty Geriatric PsychiatryProgram; Co-Chair, Canadian Coalition for Seniors’Mental Health, Kingston, Ontario

Dr. Lynn McCleary, RN, PhDConsultantAssistant Professor, Department of Nursing,Faculty of Applied Health Sciences,Brock University, St. Catharines, Ontario

Simone Powell, MPAConsultantSenior Policy Analyst, Division of Aging and Seniors,Public Health Agency of Canada;Ottawa, Ontario

Esther RobertsConsultantCaregiver, CCSMH Steering Committee Member;Calabogie, Ontario

Dr. David Conn, M.B., B.Ch., B.A.O., FRCPCCo-LeadPsychiatrist-in-Chief, Baycrest Geriatric Health CareSystem; Associate Professor, Department ofPsychiatry, University of Toronto; Co-Chair,Canadian Coalition for Seniors’ Mental Health;Past President, Canadian Academy of GeriatricPsychiatry, Toronto, Ontario

Dr. Maggie Gibson, Ph.D., C. Psych.,Co-LeadPsychologist, Veterans Care Program, St. Joseph’sHealth Care London, Associate Scientist, LawsonHealth Research Institute, Adjunct ClinicalProfessor, Department of Psychology, University ofWestern Ontario, London, Ontario

Guideline Development Group

TABLE OF CONTENTS

Section Page

Overview of Guideline Project................................................................................................................................1

Background Context ................................................................................................................................................1

Necessity for the Guideline.....................................................................................................................................1

Objectives.................................................................................................................................................................1

Principles and Scope ...............................................................................................................................................2

Target Audience........................................................................................................................................................2

Guideline Development Process ............................................................................................................................2

Literature Review - Search Strategy for Existing Evidence .....................................................................................4

Formulation of Recommendations ........................................................................................................................6

Organization of Recommendations .......................................................................................................................7

Key Concepts, Definitions and Abbreviations.......................................................................................................7

Summary of Recommendations ...........................................................................................................................10

Part 1: Background Information................................................................................................................14

1.1 Scope of Guidelines..........................................................................................................................14

1.2 Target Population..............................................................................................................................14

1.3 Prevalence..........................................................................................................................................14

1.4 Principles and Assumptions.............................................................................................................15

Part 2: General Care ..................................................................................................................................17

2.1 Introduction ......................................................................................................................................17

2.2 General Care: Discussion and Recommendations .........................................................................17

Part 3: Assessment of Mental Health Problems and Mental Disorders ....................................................22

3.1 Introduction ......................................................................................................................................22

3.2 Assessment: Discussion and Recommendations ............................................................................22

Part 4: Treatment of Depressive Symptoms and Disorders.......................................................................26

4.1 Introduction ......................................................................................................................................26

4.2 General Treatment Planning: Discussion and Recommendation .................................................26

4.3 Psychological and Social Interventions: Discussion and Recommendations...............................26

4.3.1 Comorbid Dementia .......................................................................................................29

4.4 Pharmacological Interventions: Discussion and Recommendations ............................................30

Part 5: Treatment of Behavioural Symptoms.............................................................................................32

5.1 Introduction ......................................................................................................................................32

5.2 Psychological and Social Interventions: Discussion and Recommendations...............................32

5.3 Pharmacological Interventions: Discussion and Recommendations ............................................36

Part 6: Organizational and System Issues .................................................................................................39

6.1 Introduction ......................................................................................................................................39

6.2 Organizational Issues: Discussion and Recommendations ...........................................................39

6.3 System Issues: Discussion and Recommendations .........................................................................41

Part 7: Final Thoughts, Future Directions .................................................................................................43

References...............................................................................................................................................................44

Appendix A: Process Flow Diagram .....................................................................................................................54

Appendix B: General Principles for Pharmacological Intervention ...................................................................55

National Guidelines for Seniors’ Mental Health - The Assessment and Treatment of Mental Health Issues in Long Term Care Homes 1

Background Context

The mission of the CCSMH is to promote the mental health ofseniors by connecting people, ideas and resources. The primarygoals of the CCSMH include:• To ensure that Seniors’ Mental Health is recognized as a

key Canadian health and wellness issue• To facilitate initiatives related to enhancing and promot-

ing seniors’ mental health resources• To ensure growth and sustainability of the CCSMH

In order to meet the mission and goals, a number of strate-gic initiatives are facilitated by the CCSMH with the focuson the following areas:• Advocacy and Public Awareness• Research• Education• Human Resources• Promoting Best Practices in Assessment and Treatment• Family Caregivers

In January 2005, the CCSMH was awarded funding by thePublic Health Agency of Canada, Population Health Fund,to lead and facilitate the development of evidence-basedrecommendations for best-practice National Guidelines ina number of key areas for seniors’ mental health. The fouridentified key areas for guideline development were:

1. Assessment and Treatment of Delirium2. Assessment and Treatment of Depression3. Assessment and Treatment of Mental Health Issues

in Long-Term Care Homes (focus on mood andbehavioural symptoms)

4. Assessment of Suicide Risk and Prevention ofSuicide

Between April 2005 and February 2006, workgroups wereestablished for the four identified areas. The workgroupsevaluated existing guidelines, reviewed primary literatureand formulated documents that included recommenda-tions and supporting text.

Necessity for the Guidelines

The proportion of Canadians who are seniors is expected toincrease dramatically. By 2021, older adults (i.e., those age65+) will account for almost 18% of our country’s popula-tion (Health Canada, 1999). Currently, 20% of those aged65 and older are living with a mental illness (MacCourt,2005). Although this figure is consistent with the preva-

lence of mental illness in other age groups, it does not cap-ture the high prevalence rates seen within health and socialinstitutions. For example, it has been reported that 80%-90% of nursing home residents live with some form ofmental illness and/or cognitive impairment (Rovner et al.,1990; Drance, 2005).

Previously, there were no interdisciplinary national guide-lines on the prevention, assessment, treatment and manage-ment of the major mental health issues facing olderCanadians although there are recommendations from aConsensus Conference on the assessment and managementof dementia (Patterson et al., 1999; updated version to bepublished shortly). Given the projected growth of the sen-iors’ population, the lack of an accepted national standardto guide their care is a serious problem.

There is an immediate need to identify, collaborate andshare knowledge on effective mental health assessmentand treatment practices relevant to seniors. As such, theCCSMH National Guideline Project was created to sup-port the development of evidence-based recommenda-tions in the four key areas of seniors’ mental healthidentified above.

Objectives

The overall project goal was to develop evidence-based rec-ommendations for best practice guidelines in four key areasof seniors’ mental health.

Project Objectives: 1. To identify existing best-practice guidelines in the area of

seniors’ mental health both within Canada and interna-tionally.

2. To facilitate the collaboration of key healthcare leaderswithin the realm of seniors’ mental health in order toreview existing guidelines and the literature relevant toseniors’ mental health.

3. To facilitate a process of partnership where key leadersand identified stakeholders create a set of recommenda-tions and/or guidelines for identified areas within sen-iors’ mental health.

4. To disseminate the draft recommendations and/orguidelines to stakeholders at the CCSMH Best PracticesConference 2005 in order to create an opportunity forreview and analysis before moving forward with the finalrecommendations and/or guidelines.

5. To disseminate completed guidelines to health care pro-fessionals and stakeholders across the country.

Overview of Guideline Project

2 National Guidelines for Seniors’ Mental Health - The Assessment and Treatment of Mental Health Issues in Long Term Care Homes

Principles and Scope

Guiding principles included the following:

• Evidence-based• Broad in scope• Reflective of the continuum of settings for care• Clear, concise, readable• Practical

Scope

• Must be multi-disciplinary in nature• Will focus on older adults only• Must include all health care settings across the continu-

um• Should acknowlege the variation (i.e., in services, defini-

tions, access issues, etc.) that exists between facilities,agencies, communities, regions and provinces across thecountry

• Must deal explicitly with areas of overlap between thefour National Guidelines for seniors’ mental health

• While four independent documents will be created,

there will be cross-referencing between documents asneed arises

• Gaps in knowledge will be identified and included inthe guideline documents

• Research, education and service delivery issues shouldbe included in the guidelines. For example, the guide-lines may address “optimal services”, “organizationalaspects”, “research”, and “education.”

In addition, each Guideline Development Group identi-fied scope issues specific to their topic.

Target Audience

There are multiple target audiences for these guidelines.They include multidisciplinary care teams, health careprofessionals, administrators, and policy makers whosework focuses on the senior population. In addition,these guidelines may serve useful in the planning andevaluation of health care service delivery models, humanresource plans, accreditation standards, training andeducation requirements, research needs and fundingdecisions.

Creation of the GuidelineDevelopment Group

An interdisciplinary group of experts on seniors’ mentalhealth issues were brought together under the auspices ofthe CCSMH to become members of one of the four CCSMHGuideline Development Groups. Co-leads for the GuidelineDevelopment Groups were chosen by members of theCCSMH Steering Committee after soliciting recommenda-tions from organizations and individuals. Once the Co-leads were selected, Guideline Development Groupmembers and consultants were chosen using a similarprocess, including suggestions from the Co-leads. One ofthe goals in selecting group members was to attempt to cre-ate an interdisciplinary workgroup with diverse provincialrepresentation from across the country.

Creation of the Guidelines

In May 2005, the Guideline Development Groups con-vened in Toronto, Ontario for a two-day workshop.Through large and small group discussions, the work-shop resulted in a consensus on the scope of each prac-tice guideline, the guideline template, the identification

of relevant resources for moving forward, and the devel-opment of timelines and accountability plans.

A number of mechanisms were established to minimizethe potential for biased recommendations being madedue to conflicts of interest. All Guideline DevelopmentGroup members were asked to complete a conflict ofinterest form, which was assessed by the project team.This was completed twice throughout the process. Thecompleted forms are available on request from theCCSMH. As well, the guidelines were comprehensivelyreviewed by external stakeholders from related fields onmultiple occasions.

The four individual Guideline Development Groups metat monthly meetings via teleconference with frequentinformal contact through email and phone calls betweenworkgroup members. As sections of the guidelines wereassigned to group members based on their area of expert-ise and interest, meetings among these subgroups werearranged. As well, monthly meetings were scheduledamong the Co-leads. The CCSMH project director andmanager were responsible for facilitating the processfrom beginning to end.

Guideline Development Process


Phase I: Group Administration &Preparation for Draft Documents(April/June 2005)

• Identification of Co-leads and Guideline DevelopmentGroup Members

• Meetings with Co-leads and individual Guideline Devel-opment Groups

• Establish terms of reference, guiding principles, scope ofindividual guidelines

• Development of timelines and accountability plans• Creation of guideline framework template• Comprehensive literature and guideline review• Identification of guideline and literature review tools and

grading of evidence tools

Phase II: Creation of Draft GuidelineDocuments (May/Sept. 2005)

• Meetings with co-leads & individual workgroups• Shortlist, review & rating of literature and guidelines• Summarized evidence, gaps & recommendations• Creation of draft guideline documents• Review and revisions of draft documents

Phase III: Dissemination & Consultation(May 2005/Jan. 2006)

The dissemination of the draft guidelines to external stake-holders for review and consultation occurred in the follow-ing three stages:

Stage 1: Dissemination to guideline groupmembers (May/December 2005)

Revised versions of the guidelines were disseminated toGuideline Development Group members on an ongoingbasis.

Stage 2: Dissemination to CCSMH Best Practices Con-ference participants (Sept. 2005)

In order to address issues around awareness, education,assessment and treatment practices, a national conferencewas hosted on September 26th and 27th 2005 entitled“National Best Practices Conference: Focus on Seniors’ Men-tal Health”. Those attending the conference had the oppor-tunity to engage in the process of providing stakeholderinput into the development of one of the four nationalguidelines. The full-day workshops focused on appraisingand advising on the draft national guidelines and on dis-semination strategies.

The workshop session was broken down into the followingactivities:

• Review of process, literature and existing guidelines• Review of working drafts of the guidelines• Comprehensive small and large group appraisal and

analysis of draft guidelines• Systematic creation of suggested amendments to draft

guidelines by both the small and large groups• Discussion of the next steps in revising and then dissem-

inating the guidelines. This included discussion onopportunities for further participation

Stage 3: Dissemination to guideline consultants andadditional stakeholders.(October 2005/January 2006)

External stakeholders were requested to provide overallfeedback and impressions and to respond to specificquestions. Feedback was reviewed and discussed by theGuideline Development Groups. This material was sub-sequently incorporated into further revisions of the draftguideline.

Additional stakeholders included: identified project con-sultants; Public Health Agency of Canada, Federal/ Provin-cial/Territorial government groups; CCSMH members andparticipating organizations; CCSMH National Best PracticesConference workshop participants; Canadian Academy ofGeriatric Psychiatry; and others.

Phase IV: Revised Draft of GuidelineDocuments (Oct. 2005/Jan. 2006)

• Feedback from the Best Practices Conference Workshopswas brought back to the Guideline Development Groupsfor further analysis and discussion

• Feedback from external stakeholders was reviewed anddiscussed

• Consensus within each guideline group regarding recom-mendations and text was reached

• Final revisions to draft guideline documents

Phase V: Completion of Final GuidelineDocument (Dec. 2005/Jan. 2006)

• Final revisions to draft guideline documents by GuidelineDevelopment Groups

• Completion of final guidelines and recommendationsdocument

• Final guidelines and recommendations presented to thePublic Health Agency of Canada

Phase VI: Dissemination of Guidelines(Jan. 2006 - onwards)

• Identification of stakeholders for dissemination• Translation, designing and printing of documents• Dissemination of the documents to stakeholders through

electronic and paper form• Marketing of guidelines through newsletters, conference

presentations, journal papers, etc.

See Appendix A for the detailed Process Flow Diagram out-lining the development of the guidelines.


A strategic and comprehensive review of the existingresearch literature on the assessment and managementof mood and behaviour symptoms in LTC homes wascompleted.

Search Strategy for Existing Evidence

A computerized search for relevant evidence-based sum-maries, including guidelines, meta-analyses, and litera-ture reviews, and research literature not contained inthese source documents, was conducted by librarian con-sultants to the Guidelines Project and by the CCSMH.The search strategy was guided by the following inclu-sion criteria:• English language references only• References specifically addressed depressive and/or

behaviour symptoms in LTC homes• Guidelines, meta-analyses and reviews were dated

January 1995 to May 2005• Research articles were dated January 2000 to June 2005

Guideline, Meta-analyses and LiteratureReviews Search

The initial search for existing evidence-based summaries(e.g., guidelines, protocols) examined several major data-bases, specifically, Medline, EMBASE, PsycInfo, CINAHL,AgeLine, and the Cochrane Library. The following searchterms were used: “long term care”, “residential care insti-tutions”, “nursing homes”, “homes for the aged”, “agita-tion”, “wandering”, “agitated behavior”, “bipolardisorder”, “depression”, “mood disorders”, “affective dis-orders”, “social behavior disorders”, “behavioral symp-toms”, “dementia”, “delirium”, “disruptive behavior”,“elderly”, “older adult(s)”, “aged”, “geriatric”, “guide-line(s)”, “practice guideline(s)”, “practice guideline(s)older adults”, “protocol(s)”, “best practice guideline(s)”,and “clinical guide-line(s)”.

In addition, a list of websites was compiled based onknown evidence-based practice websites, known guidelinedevelopers, and recommendations from Guideline Devel-opment Group members. The search results and dates werenoted. The following websites were examined:

• American Medical Association:http://www.ama-assn.org/

• American Psychiatric Association:http://www.psych.org/

• American Psychological Association:http://www.apa.org/

• Annals of Internal Medicine: http://www.annals.org/• Association for Gerontology in Higher Education:

http://www.aghe.org/site/aghewebsite/

• Canadian Mental Health Association:http://www.cmha.ca/bins/index.asp

• Canadian Psychological Association:http://www.cpa.ca/

• National Guidelines Clearinghouse:http://www.guideline.gov/

• National Institute on Aging: http://www.nia.nih.gov/• National Institute for Health and Clinical Excellence:

http://www.nice.org.uk/• National Institute of Mental Health:

http://www.nimh.nih.gov/• Ontario Medical Association: http://www.oma.org/• Registered Nurses Association of Ontario:

http://www.rnao.org/• Royal Australian and New Zealand College of

Psychiatrists: http://www.ranzcp.org/• Royal College of General Practitioners:

http://www.rcgp.org.uk/• Royal College of Nursing: http://www.rcn.org.uk/• Royal College of Psychiatrists:

http://www.rcpsych.ac.uk/• World Health Organization: http://www.who.int/en/

This search yielded 26 potentially relevant guidelines.These were further considered by the Guideline Develop-ment Group Co-leads as to whether they specificallyaddressed the guideline topic and were accessible eitheron-line, in the literature, or through contact with thedevelopers. Through this process, 10 guidelines wereselected and obtained for inclusion in the literature basefor the project. These 10 guidelines were:

• Alexopoulos, GS, Jeste DV, Chung H, Carpenter D,Ross R, & Docherty JP. The expert consensus guidelineseries: Treatment of dementia and its behavioural dis-turbances. A Postgrad Med Special Report 2005.

• American Geriatrics Society, American Associationfor Geriatric Psychiatry (AGS/AAGP). Consensus state-ment on improving the quality of mental health carein U.S. nursing homes: management of depression andbehavioural symptoms associated with dementia.Journal of American Geriatrics Society 2003;51(9):1287-98.

• American Medical Directors Association (AMDA).Depression: clinical practice guidelines. Columbia(MD): AMDA; 2003. Available: www.amda.ca

• Doody RS, Stevens JC, Beck C, Dubinsky RM, Kaye JA,Gwyther L, et al. Practice parameter: management ofdementia (an evidence-based review). Report of thequality standards subcommittee of the American Acad-emy of Neurology. Neurology 2001;56(9):1154-66.

Literature Review


• Futrell M, Melillo KD. Evidence-based protocol: Wan-dering. Iowa City (IA): University of Iowa Gerontolog-ical Nursing Interventions Research Centre, ResearchDissemination Core; 2002. Available: http://www.guideline.gov/summary/summary.aspx?doc_id=3250&nbr=002476&string=002476

• Gerdner L. Evidence-based protocol: Individualizedmusic. Iowa City (IA): University of Iowa Gerontologi-cal Nursing Interventions Research Centre, ResearchDissemination Core; 2001. Available: http://www.guideline.gov/summary/summary.aspx?doc_id=3073&nbr=002299&string=002299

• McGonigal-Kenney ML, Schutte DL. Non-pharmaco-logical management of agitated behaviours in personswith Alzheimer’s disease and other chronic dementingconditions. Iowa City (IA): University of Iowa Geron-tological Nursing Interventions Research Center,Research Dissemination Core; 2004. Available: http://www.guideline.gov/summary/summary.aspx?doc_id=6221&nbr=003992&string=003992

• Registered Nurses Association of Ontario (RNAO).Caregiving strategies for older adults with delirium,dementia and depression. Toronto (ON): RegisteredNurses Association of Ontario; 2004. Available:http://www.rnao.org/bestpractices/completed_guide-lines/BPG_Guide_C4_caregiving_elders_ddd.asp

• Registered Nurses Association of Ontario (RNAO).Screening for delirium, dementia and depression inolder adults. Toronto (ON): Registered Nurses Associa-tion of Ontario; 2003. Available: http://www.rnao.org/bestpractices/completed_guidelines/BPG_Guide_C3_ddd.asp

• Thiru-Chelvam B. Bathing persons with dementia.Iowa City (IA): University of Iowa GerontologicalNursing Interventions Research Center, Research Dis-semination Core; 2004 Available: http://www.guide-line.gov/summary/summary.aspx?doc_id=6220&nbr=003991&string=003991

The Guideline Development Group used the Appraisal ofGuidelines for Research and Evaluation Instrument (AGREE)(AGREE Collaboration, 2001) to appraise the mostdirectly relevant previously published guideline: AGS/AAGP (2003). This process served both to confirm ourconfidence in reliance on this source, and enhanceawareness of the factors to be taken into consideration inrelying on evidence and recommendations from othersource guidelines in the development of our contribu-tion to this literature.

In addition, the search yielded several relevant CochraneLibrary reviews, and a number of key review articles. Thereference lists for these articles were hand searched by mem-

bers of the Guideline Development Group for relevantresearch articles and 35 of these were obtained in full text asa component of the initial search strategy.

Supplemental Research Literature Search

The timeframe (2000-2005) for the supplementalresearch literature search was selected in consideration ofthe publication dates of the relevant guidelines, as it wasassumed that these guidelines, collectively, could berelied on as acceptable sources of the prior literature.

Searches were conducted separately for each database(Medline, EMBASE, PsycInfo, CINAHL, AgeLine, theCochrane Library), with necessary variance in controlledvocabulary (i.e., minor differences in search terms as pro-scribed by each database). The core search strategy for alldatabases was to limit it to papers dealing with humans,written in English, and published between 2000 and2005.

Each search also included terms to encompass location(i.e. exploded terms: long term care, nursing home, resi-dential care institutions), age (aged) and symptoms/dis-orders (i.e. affective disorders, behaviour disorders,mood disorders, psychotic disorders, cognitive disorders,depression, dementia, delirium, amnesic, senile demen-tia, behavioural symptoms, inappropriate sexual behav-iour, disruptive behaviour, social behavioural disorders,mental disorders, obsessive-compulsive disorder, psy-chophysiologic disorders).

As expected, search term combinations yielded low ratesfor relevant citations. For example, in Medline, a searchfor five of the disorders noted above (i.e., social behav-ioural disorders or mental disorders or etc.) yielded97951 hits. However, when search terms "long term care"(exploded) and "aged" were added to the search, theyield dropped to 95 citations. In order to further focusthe search, the 95 abstracts were audited on-line, result-ing in the identification of 12 studies that were relevantand applicable to this project.

The librarian and project Co-lead followed a similarprocess (database search followed by on-line audit) forvarious search combinations. Through this process, 56potentially relevant articles, not previously identifiedthrough the search for evidence-based summaries (i.e.guidelines, meta-analyses and literature reviews), werefound. Abstracts were circulated to members, and 32recent research articles were selected. Full text articleswere obtained to add to the literature base. As the devel-opment of the guideline document progressed, addition-al literature (i.e. summaries and research articles) wasidentified through targeted searches and expert knowl-edge contributions on the part of the Guideline Develop-ment Group. The resultant reference base includes over200 citations.


The selected literature was appraised with the intent ofdeveloping evidence-based, clinically sound recommen-dations. Based on relevant expertise and interest, theGuideline Development Group was divided into sub-groups and completed the drafting of recommendationsfor their particular section. The process generated severaldrafts that were amalgamated into a single documentwith a set of recommendations confirmed by consensus.Thus, the recommendations are based on research evi-dence, informed by expert opinion.

The strength of each recommendation was assessed usingShekelle and colleagues’ (1999) Categories of Evidenceand Strength of Recommendations. Prior to the CCSMHBest Practices Conference, the Guideline DevelopmentGroup Co-leads reviewed the draft documents andapproved the recommendations. After the conference,each Guideline Development Group reviewed their rec-ommendations and discussed gaps and controversies.Areas of disagreement were discussed and recommenda-tions were endorsed. A criterion of 80% consensus insupport of a recommendation among Guideline Devel-opment Group members was required for the inclusionof a recommendation in the final document. In reality,consensus on the final set of recommendations wasunanimous.

The evidence and recommendations were interpretedusing the two-tier system created by Shekelle and col-leagues (1999). The individual studies are categorizedfrom I to IV. The category is given alongside the refer-ences and has been formatted as (reference).Category of Evidence

Categories of evidence forcausal relationships and treatment

Evidence from meta-analysis ofrandomized controlled trials Ia

Evidence from at least onerandomized controlled trial Ib

Evidence from at least onecontrolled study without randomization IIa

Evidence from at least one othertype of quasi-experimental study IIb

Evidence from non-experimentaldescriptive studies, such ascomparative studies, correlationstudies and case-control studies III

Evidence from expert committeesreports or opinions and/or clinicalexperience of respected authorities IV

(Shekelle et al., 1999)

The strength of the recommendations, ranging from A toD (see below), is based on the entire body of evidence(i.e., all studies relevant to the issue) and the expert opin-ion of the Guideline Development Group regarding theavailable evidence. For example, a strength level of D hasbeen given to evidence extrapolated from literature onyounger population groups or is considered a good prac-tice point by the Guideline Development Group.

Given the difficulties (e.g., pragmatic, ethical and con-ceptual) in conducting randomized controlled trials witholder persons in LTC homes, it was important for theGuideline Development Group to assess and use the evi-dence of those trials that incorporated quasi-experimen-tal designs (Tilly & Reed, 2004).

It is important to interpret ratings for the strength of rec-ommendation (A to D) as a synthesis of all the underlyingevidence and not as a strict indication of the relevantimportance of the recommendation for clinical practice orquality of care. Some recommendations with little empiri-cal support, resulting in a lower rating for strength on thisscale, are in fact critical components of service delivery inthe LTC setting. Level of risk has also been consideredwhen assigning strength of recommendation.

Strength of recommendation

Directly based on category I evidence A

Directly based on category II evidenceor extrapolated recommendationfrom category I evidence B

Directly based on category III evidenceor extrapolated recommendationfrom category I or II evidence C

Directly based on category IV evidenceor extrapolated recommendationfrom category I, II, or III evidence D

(Shekelle et al., 1999)

Formulation of Recommendations


Following a discussion of Background Information (Part1), recommendations are presented and discussed in thesubsequent sections of this Guideline.

In Part 2: General Care, we provide recommendations forthe delivery of care to all LTC residents, in the interest ofmental health promotion.

In Part 3: Assessment of Mental Health Problems and MentalHealth Disorders, we provide recommendations for theassessment of depressive and behavioural symptoms inLTC residents. In the assessment section, depressive andbehavioural symptoms are considered together, exceptfor where the literature is specific to one or the othersymptom pattern.

In contrast, in Part 4: Treatment of Depressive Symptomsand Disorders, and Part 5: Treatment of BehaviouralSymptoms, symptoms are discussed separately, for a num-ber of reasons. For example, there is empirical supportfor specific psychotherapies (e.g., cognitive-behavioural

therapy) for treatment of depressive symptoms, but notfor behavioural symptoms. While activity therapy andsocial contact interventions have been suggested for bothsymptom presentations, the types of activities and socialcontact interventions that have been empirically sup-ported differ. For example, social contact intervention fordepression includes peer volunteers, while one-to-oneinteractions, pet-therapy and simulated interactions havebeen investigated for behavioural symptoms. In addi-tion, pharmacological treatment of these symptoms/syn-dromes includes different medications and must takeinto account the underlying diagnosis. Importantly, whilepsychosocial and pharmacological interventions are dis-cussed sequentially for clarity within each symptom set(depressive versus behavioural), it is acknowledged thatinterventions often are, and should be integrated in prac-tice (Cohen-Mansfield, 2001).

In Part 6: Organizational and System Issues, we provide rec-ommendations that apply to the broader context of caredelivery, at the facility and system level.

Organization of Recommendations

Key Concepts and Definitions

There are several key concepts and definitions thatunderpin the discussion of the literature and formula-tion of the recommendations presented in this docu-ment. In alphabetical order, these are as follows:

Assessment: is understood to be a comprehensive, ongo-ing process, that includes: (1) screening to detect depres-sive and behavioural symptoms; (2) structured, goal-directed investigation to identify factors precipitating,maintaining and exacerbating identified symptoms,which leads to client-centered, evidence-based interpre-tation of assessment findings, including formal diagno-sis where appropriate; and (3) ongoing evaluation ofclinical outcomes and treatment effectiveness to deter-mine the need for reassessment and re-conceptualizationof contributing factors.

Assessment Protocol: is understood to refer to a prob-lem-oriented framework that guides thinking about anissue. An assessment protocol structures the decision-making process so that the assessment process is effi-cient, yet comprehensive enough to lead to an appropri-ate care plan for an individual resident. The interRAIsuite of tools (including the Minimum Data Set) pro-vides an example of a research-based, standardizedapproach to the development of assessment protocols(www.interRAI.org, 2006; Morris et al., 1995). Assess-

ment protocols and processes should be supported withspecific timelines and staff accountabilities (expertiseand scope of practice) for optimal effectiveness.

Behavioural Symptoms: are understood to includeobservable behaviours that are: (1) inappropriate orexcessive within the context of the situation/setting; and(2) disturbing, disruptive or potentially harmful to theresident and/or others.

Depressive Symptoms: are understood to include thosesymptoms that constitute a diagnosis of MajorDepressive Disorder or the proposed diagnosis of MinorDepressive Disorder, or other mood disorders, accordingto the Diagnostic and Statistical Manual of Mental DisordersFourth Edition Text Revision (DSM-IV-TR) criteria(American Psychiatry Association (APA), 2000a). It isacknowledged that depressive symptom presentation inolder adults may be atypical, subsyndromal or difficultto distinguish from other comorbid conditions.

Interdisciplinary Team: is understood to include a vari-ety of disciplines, representing both facility based staffand external consultants. It is acknowledged that there isno consensus on the optimal mix of expertise and scopesof practice, and within any given facility, clinicalresources may differ. However, a key concept underlyingthese Guidelines is that effective mental health promo-tion and management of mental health problems,

Key Concepts, Definitions and Abbreviations


including mental disorders, requires an interdisciplinaryteam effort. It is beyond the scope of these Guidelines topropose criteria for interdisciplinary team compositionwithin LTC homes, or to address the challenges ofresource availability. However, the centrality of this issuefor the implementation of these best practice recommen-dations is acknowledged. In this document, careproviders refer to members of interdisciplinary teamsand staff.

Long Term Care Homes: For the purpose of theseGuidelines, the term long term care homes (LTC) is usedgenerically. This term is used to refer to any congregateliving residence, created for older adults and others withchronic illnesses, disabilities, and/or deficits in activitiesof daily living (ADL) or instrumental activities of dailyliving (IADL) that necessitate skilled nursing care on adaily basis. This would include, for example, facilitiesknown as nursing homes and complex care facilities. It isacknowledged that there is wide variability in how LTChomes are defined, funded and structured in differentprovinces and territories. It is also recognized that thereis variation of services within and across retirementhomes and assisted living facilities. Recommendationsfrom these Guidelines may serve useful to these alterna-tive settings for care as well.

Management: is understood to include interventionsintended to modify the milieu (social and/or physicalenvironment) to prevent the potential for depressive orbehavioural symptoms (e.g., changes in the facility din-ing room to promote increased or appropriate opportu-nities for interaction), and interventions intended toaddress existing depressive or behavioural symptomsexperienced by a resident. Thus, management includes,but is broader than, formal assessment and treatment.

Mental Disorders: are understood to include those con-ditions defined in the DSM-IV-TR, a multiaxial classifica-tion system (APA, 2000a). The five axes are: 1) ClinicalDisorders, Other Conditions that may be a focus ofClinical Attention; 2) Personality Disorders, MentalRetardation; 3) General Medical Conditions; 4)Psychosocial and Environmental Problems; and 5)Global Assessment of Functioning.

Mental Health: is understood as “the capacity of theindividual, the group and the environment to interactwith one another in ways that promote subjective well-being, the optimal development and use of mental abil-ities (cognitive, affective and relational), the achievementof individual and collective goals consistent with justiceand the attainment and preservation of fundamentalequality” (Health and Welfare Canada, 1988). Althoughmental health is conceptualized as an individualresource, it is affected by the social context in which theindividual lives. Key aspects of mental health for olderadults include autonomy, self-esteem, relationships, andsocial supports (Waters, 1995). Mental health is a broadconcept, and mental health care, like health care in gen-

eral, can be viewed along a continuum from promotionof good mental health to treatment of serious mental ill-ness (American Association for Retired People (AARP),1994).

Mental Health Problems: are understood to reflect inter-nal causes (e.g., physical or mental illness, inadequatecoping skills) and/or external causes (e.g., interactionswith the social and/or physical environment; relation-ship dynamics) (Health and Welfare Canada, 1988).Both bio-medical and non-biomedical factors that canaffect mental health must therefore be taken intoaccount when identifying or addressing seniors’ mentalhealth problems. Mental health problems include dis-crete mental disorders. Mental health problems in latelife often occur in the context of medical illness, disabil-ity, and psychosocial impoverishment.

Mental Health Promotion: is understood as the processof enhancing the capacity of residents to take controlover their lives and improve their mental health. Forexample, by working to increase self-esteem, copingskills, social support and well-being in all individuals,mental health promotion empowers residents to interactwithin their social and physical environment in waysthat enhance emotional and spiritual strength. Mentalhealth promotion serves to foster individual resilienceand promote a socially supportive milieu within the LTCfacility. Mental health promotion includes challengingdiscrimination and stigma against those with mentalhealth problems.

Resident: For the purpose of these Guidelines, the termresident is used to refer to older adults who live in LTChomes. A key concept is that each resident is an individ-ual, who deserves an individualized approach to caredelivery. It is acknowledged that the target populationencompasses a heterogeneous group of individuals, wide-ly varied not only in chronological age (65 to plus 100years of age), but also in culture, ethnicity, race and sexu-al orientation. Given the state of knowledge, no attempt ismade to refine recommendations as a function of popula-tion subgroups, although the significance of respect forcultural diversity and need for further research in this areais acknowledged. It is further acknowledged that youngeradults may also reside in LTC homes, for example, indi-viduals with acquired brain injuries or developmentaldelays. The content of these Guidelines may be relevant tothese residents as well. However, the focus of this litera-ture review and subsequent development of guidelineshas been on older adults.

Treatment: is understood to include specific therapeuticinterventions (i.e., psychological and social, as well aspharmacological) for an identified problem at the levelof the individual resident (i.e., in this context, depressiveand/or behavioural symptoms that warrant interven-tion). Treatment should follow an individualized assess-ment, and treatment effectiveness should be monitoredand evaluated.


Abbreviations

There are a number of abbreviations utilized within thisguideline. In alphabetical order, these are as follows:

AAGP: American Association for Geriatric Psychiatry

AAI: Abilities Assessment Instrument

AARP: American Association of Retired Persons

ABC: Antecedents-Behaviour-Consequences

AD: Alzheimer’s Disease

ADL: Activities of Daily Living

AGS: American Geriatrics Society

AMDA: American Medical Directors Association

APA: American Psychiatric Association

APN: Advanced Practice Nurse

BARS: Brief Agitation Rating Scale

BEHAVE-AD: Behaviour Pathology in Alzheimer’s DiseaseRating Scale

BLT: Bright Light Therapy

BMT: Behaviour Management Training

BPSD: Behavioural and Psychological Symptoms ofDementia

BSSD: Behavioural Symptoms Scale for Dementia

CANMAT: Canadian Network for Mood and AnxietyTreatments

CES-D: Centre for Epidemiological Studies of DepressionScale

CMAI: Cohen-Mansfield Agitation Inventory

CPA: Canadian Psychiatric Association

CSDD: Cornell Scale for Depression in Dementia

DLB: Dementia with Lewy Bodies

DSM-IV-TR: Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition Text Revision

ECT: Electroconvulsive Therapy

FAI: Feeding Abilities Assessment

GDS: Geriatric Depression Scale

HPRD: Hours Per Resident per Day

IADL: Instrumental Activities of Daily Living

KU: Knowledge Utilization

LTC: Long Term Care

MDS: Minimum Data Set

MMSE: Mini-Mental Status Examination

NPI: Neuropsychiatric Inventory

PAS: Pittsburgh Agitation Scale

POA: Powers of Attorney

PRN: Pro Re Nata (as needed)

PST: Problem-Solving Therapy

RCT: Randomized Controlled Trial

RNAO: Registered Nurses Association of Ontario

SCN: Suprachiasmatic Nuclei

SSRI: Selective Serotonin Reuptake Inhibitors

TCA: Tricyclic Antidepressant


All recommendations are presented together at the beginningof this document for easy reference. Subsequently, in each sec-tion we present the recommendation followed by a discussionof the relevant literature. We strongly encourage readers to

refer to the supplemental text discussion, rather than onlyusing the summary of recommendations. The page numbersfor the corresponding text are given with the recommenda-tions below.

Summary of Recommendations

Recommendations: General Care

Recommendation: General Care – Family Involvement (p. 17)

Encourage and support the involvement and education of the family in the institutional life of the older resident,including decision-making processes, as appropriate. [C]

Recommendation: General Care – Care Plan (p. 18)

Individualize care plans, with due consideration to best practice guidelines and recommendations. [D]

Recommendation: General Care – Communication (p. 18)

Implement strategies to promote communication between care providers and residents. [B]

Recommendation: General Care – Dressing (p. 19)

Develop an individualized approach when assisting the resident with dressing. [B]

Recommendation: General Care – Bathing (p. 20)

Develop an individualized protocol for each resident that minimizes negative affect and promotes a sense of wellbeing during bathing. [A]

Recommendation: General Care – Activities (p. 20)

Consider the need to pace activities that residents are involved in throughout the day. [B]

Recommendation: General Care – Mealtime (p. 20)

Consider the need to develop mealtime care-giving activities to enhance nutrition and prevent behaviours that inter-fere with nutritional and social needs. [D]

Recommendations: Assessment of Mental Health Problemsand Mental Disorders

Recommendations: Assessment – Screening (p. 22 -23)

The facility’s assessment protocol should specify that screening for depressive and behavioural symptoms will occurboth in the early post-admission phase and subsequently, at regular intervals, as well as in response to significantchange. [C]

A variety of screening tools that are appropriate to the setting and resident population should be available to facil-itate the screening process. [D]

Tool selection should be determined by the characteristics of the situation (e.g., resident capacity for self-report,nature of the presenting problem). [D]


Screening should trigger detailed investigation of depressive and behavioural symptoms under defined circum-stances. [D]

Recommendations: Assessment – Detailed Investigation (p. 23 – 25)

Core elements of a detailed investigation should include history and physical exam, with follow up laboratory andpsychological investigations, investigations of the social and physical environment, and diagnostic tests as indicat-ed by the results of the history and physical exam, and treatment history and response. [C]

It is important to consider all contributing factors. Investigation of potentially contributing factors (e.g., delirium,chronic pain) should refer to clinical practice guidelines for these conditions where available. [D]

Diagnosis and differential diagnosis should be an assessment objective where appropriate. [D]

The end point of a detailed investigation should be the determination of the need for, type, and intensity of treat-ment. [D]

Recommendations: Assessment – Ongoing Evaluation (p. 25)

The treatment plan should specify the timeline and procedure for ongoing evaluation of clinical outcomes and treat-ment effectiveness. [D]

Ongoing evaluation should include history and assessment of change in the target symptoms. [D]

Assessment of change should include quantification, preferably with the same tool that was used pre-intervention.[D]

Unexpected clinical outcomes and treatment effects should trigger re-assessment and potentially re-conceptualiza-tion of the factors precipitating, maintaining and exacerbating depressive and behavioural symptoms. Potentialadverse reactions to treatment should be evaluated. [D]

Recommendations: Treatment of Depressive Symptoms and Disorders

Recommendation: Depressive Symptoms: General Treatment Planning (p. 26)

Consider type and severity of depression in developing a treatment plan. [B]

Recommendation: Depressive Symptoms: Psychological and Social Interventions (p. 27 – 28)

Social contact interventions, including interventions that promote one’s sense of meaning, should be consideredwhere the goal is to reduce depressive symptoms. [C]

Structured recreational activities should be considered where the goal is to engage the resident. [C]

Psychotherapies should be considered where the goal is to reduce depressive symptoms. [B]

Self-affirming interventions (e.g. validation and reminiscence therapies) should be considered where the goal is toincrease sense of self-worth and overall well-being. [C]

Recommendation: Depressive Symptoms: Psychological and Social Interventions (p. 29)

Consider the impact of comorbid dementia in developing a treatment plan. [C]

Recommendation: Depressive Symptoms: Pharmacological Interventions (p. 30 – 31)

First line treatment for residents who meet criteria for major depression should include an antidepressant. [A]


Appropriate first line antidepressants for LTC home residents include selective serotonin reuptake inhibitors (e.g.,citalopram and sertraline), venlafaxine, mirtazapine, buproprion. [B]

For residents with major depression with psychotic features, a combination of antidepressant and antipsychoticmedications is appropriate. [B]

Residents with a first episode of major depression responding well to antidepressant treatment should continue onfull dose treatment for at least 12 months. Residents who have had at least one previous episode of depressionshould continue with treatment for at least two years. [A]

The treatment of depressed residents with a history of bipolar mood disorder should include a mood stabilizer suchas lithium carbonate, divalproex sodium or carbamazepine. [B]

Residents with severe depression not responding to medications should be considered for a trial of electroconvul-sive therapy (ECT). (These residents will likely require transfer to a psychiatric facility). [B]

Psychostimulants (e.g., methylphenidate) may have a role in treating certain symptoms which are commonly asso-ciated with depression (e.g., apathy, decreased energy). [C]

Recommendations: Treatment of Behavioural Symptoms

Recommendation: Behavioural Symptoms: Psychological and Social Interventions (p. 32 – 35)

Social contact interventions should always be considered, especially where the goal is to minimize sensory depriva-tion and social isolation, provide distraction and physical contact, and induce relaxation. [C]

Sensory/relaxation interventions (e.g., music, snoezelen, aromatherapy, bright light) should be considered wherethe goal is to reduce behavioural symptoms, stimulate the senses and enhance relaxation. [B/D]

Structured recreational activities should be considered where the goal is to engage the resident. [C]

Individualized behaviour therapy should be considered where the goal is to manage behaviour symptoms (e.g., con-textually inappropriate, disturbing, disruptive or potentially harmful behaviours). [C]

Recommendation: Behavioural Symptoms: Pharmacological Interventions (p. 36 – 38)

Carefully weigh the potential benefits of pharmacological intervention versus the potential for harm. [A]

Appropriate first line pharmacological treatment of residents with severe behavioural symptoms with psychotic fea-tures includes atypical antipsychotics. [B] Atypical antipsychotics should only be used if there is marked risk, dis-ability or suffering associated with the symptoms. [C]

Appropriate first line pharmacological treatment of residents with severe behavioural symptoms without psychoticfeatures can include: a) atypical antipsychotics; b) antidepressants such as trazodone or selective serotonin reuptakeinhibitors (e.g., citalopram or sertraline). Antipsychotics [B]; Antidepressants [C]

Pharmacological treatment of residents with severe behavioural symptoms can also include: a) anticonvulsants such ascarbamazepine; b) short or intermediate acting benzodiazepines. Carbamazepine [B]; Benzodiazepines. [C]

Appropriate pharmacological treatment of residents with severe sexual disinhibition can include: a) hormone ther-apy (e.g., medroxyprogesterone, cyproterone, leuprolide); b) selective serotonin reuptake inhibitors; or c) atypicalantipsychotics. [D]

Appropriate pharmacological treatment of behavioural symptoms associated with frontotemporal dementia caninclude trazodone or selective serotonin reuptake inhibitors. [B]


Appropriate pharmacological treatment of residents with behavioural symptoms or psychosis associated withParkinson’s disease or dementia with Lewy bodies includes: a) cholinesterase inhibitors; or as a last resort b) anatypical antipsychotic with less risk of exacerbating extrapyramidal symptoms, (e.g., quetiapine). Cholinesteraseinhibitors [B]; Quetiapine. [C]

Pharmacological treatments for behavioural symptoms or psychosis associated with dementia should be evaluatedfor tapering or discontinuation on a regular basis (e.g., every 3-6 months). Ongoing monitoring for adverse effectsshould be under taken. [A]

Recommendations: Organizational and System Issues

Recommendation: Organizational Issues (p. 39 – 41)

LTC homes should develop the physical and social environment as a therapeutic milieu through the intentional useof design principles. [D]

LTC homes should have a written protocol in place related to staffing needs specific to the care of older residentswith mood and/or behavioural symptoms. [C]

LTC homes should have an education and training program for staff related to the needs of residents with depres-sion and/or behavioural concerns. Ideally dedicated internal staff would be available to provide leadership in thisarea, including the development and delivery of best practices. [C]

LTC homes should have a written protocol in place related to the administration of medication by para-profession-al staff. [D]

LTC homes should have a written policy in place regarding the use of restraints. [D]

Recommendation: System Issues (p. 41 – 42)

LTC homes should obtain mental health services from local practitioners or multidisciplinary teams, with interestand expertise in geriatric mental health issues. [D]

Administrators and managers within LTC homes should be prepared to advocate with local, provincial, and nation-al policy makers and funding agencies to promote the health and well being of older residents. [D]

LTC homes should have a process in place that ensures adherence to the ethical and legislative rights of the olderresident. [D]

LTC homes should ensure adequate planning, allocation of required resources and organizational and administra-tive support for the implementation of best practice guidelines. [D]

LTC homes should monitor and evaluate the implementation of best practice recommendations. [D]


1.1 Scope of Guidelines

These Guidelines are intended to promote mental healthand address mental health problems (including mentaldisorders) in older residents of LTC homes. The specificfocus is on depressive and behavioural symptoms. Weinclude recommendations that address general care andsystem issues, as well as recommendations for the assess-ment and treatment of depressive and behavioural symp-toms presented by individual residents.

1.2 Target Population: Older Adults whoReside in Long Term Care Homes

In recent decades as the elderly population in modernindustrial countries has rapidly increased, the number ofseniors receiving care in LTC homes has also increaseddramatically. In Canada the actual number has risenfrom 203,000 in 1986 to 240,000 in 1996 (NationalAdvisory Council on Aging, 1999) and this number iscontinuing to increase. By 2021, seniors will account for18% of the population for a total of 6.7 million people(Health Canada, 1999). Projections for 2031 suggest thatthe number of LTC beds will triple or even quadruple.The population aged 85 and over is growing at the fastestrate and this is the group that is most likely to requireLTC. According to Statistics Canada, in 1996 38% of allwomen aged 85 and over lived in an institution, com-pared with 24% of similarly aged men (Health Canada,2002).

The rate of institutionalization varies somewhat betweenCanadian provinces. Seniors are least likely to be institu-tionalized in British Columbia, where 5.4% of seniorslive in institutions (Health Canada, 1999). In contrast,seniors are most likely to be institutionalized in Quebec,Prince Edward Island or Alberta. The statistics fromQuebec reflect the fact that many seniors in that provincereside in a religious institution (Health Canada, 1999).Important worldwide trends in nursing home careinclude: a) a growth in the physical size of homes; b) anincrease in the availability of higher levels of care; c) asignificantly greater percentage of residents with demen-tia and severe cognitive impairment; d) more residentswith psychiatric and behavioural disorders; e) the devel-opment of national standards and legislation in somecountries; and f) attempts to humanize LTC homes byoptimizing the physical and social environment.

There is evidence that the majority of elderly residents ofnursing homes are somewhat disabled and require aconsiderable degree of care and assistance. In the 1995U. S. National Nursing Home Survey, 96.9% of residentsrequired assistance with at least one activity of daily liv-ing, including: 96% requiring assistance with bathing,86% with dressing, 58% with toileting and 45% with

eating (U.S. National Center for Heath Statistics, 1997).In addition, there is evidence that one’s inability to per-form the activities of daily living contribute significantlyto the final decision regarding admission to a nursinghome.

1.3 Prevalence of Mental Health Problemsand Mental Health Disorders in LongTerm Care Residents

The literature suggests that there is an extremely highprevalence of mental disorders among nursing home res-idents. Recent studies using sophisticated methodsreport prevalence rates of between 80% and 90%. Forexample, one of the most rigorous studies was carriedout by Rovner and colleagues (1990), who reported theprevalence of specific psychiatric disorders in 454 con-secutive nursing home admissions. More than two thirdsof the residents had some form of dementia, 10% suf-fered from affective disorders and 2.4% were diagnosedas having schizophrenia or another psychiatric illness.Forty percent of the residents suffering from dementiahad psychiatric complications such as depression, delu-sions or delirium.

Depression is extremely common in the nursing homesetting. Studies suggest that between 15% and 25% ofnursing home residents have symptoms of MajorDepression and another 25% have depressive symptomsof lesser severity (Ames, 1990; Katz et al., 1989). Theincidence of newly diagnosed depression has been esti-mated to be 12-14% per year, with about half of all newcases meeting criteria for major depression. In addition,follow-up studies of residents with mild depression haveshown that many are likely to become more significant-ly depressed over time. It can be difficult to confirm adiagnosis of depression, particularly in patients with co-existing dementia and/or chronic medical illness. Thereis evidence to suggest that depression can contribute sig-nificantly to a general deterioration of health in seniors.Decreased food and fluid intake may lead to under-nutri-tion, dehydration, weight loss and impaired resistance toinfection. Studies also suggest that depression is associat-ed with increased mortality rates in LTC with a relativerisk of between 1.5 and 3, as compared to non-depressedpatients (Borson & Fletcher, 1996).

The prevalence of psychosis in nursing home residentsappears to range from 12-21% depending on how psy-chotic symptoms are measured. One study reported that21% of newly admitted nursing home residents haddelusions (Morriss et al., 1990). The differential diagno-sis of psychosis in the elderly includes many disorders,ranging from schizophrenia to delusional disorder,mood disorders and delirium. Although there are a rela-tively low number of residents with schizophrenia, this is

Part 1: Background Information


a particularly difficult group to treat in the LTC setting.Some seniors who have suffered from schizophrenia formost of their lives have been transferred from psychiatricinstitutions to LTC homes, which generally have limitedmental health workers available.

Individuals with dementia suffer from cognitive impair-ment, usually consisting of memory impairment anddifficulty in at least one other cognitive area. In addi-tion to memory disturbance, many residents withdementia also have behavioural symptoms, whichinclude agitation, aggression, wandering, repetitive orbizarre behaviours, shouting, disinhibited behavioursand sexually inappropriate behaviour. Agitation hasbeen defined as “inappropriate verbal, vocal or motoractivity unexplained by apparent needs or confusion”(Cohen-Mansfield & Billig, 1986). Agitated behaviourscan be categorized as disruptive, but non-aggressive,socially inappropriate or aggressive. Aggression can bedefined as hostile actions directed towards others, theself or objects, and can be categorized further as physi-cal, verbal or sexual. A review of the literature regardingthe prevalence of the behavioural and psychologicalsymptoms of dementia reported median figures of 44%for global agitation, 24% for verbal aggression and 14%for physical aggression (Tariot & Blazina, 1994).Individuals who demonstrate signs of acute confusionmay be suffering from delirium, which is generally areversible condition precipitated by a physical illness ormedications. Patients suffering from delirium may beextremely agitated or alternatively may become with-drawn and drowsy to the point of stupor. For moreinformation on delirium, please refer to the companionNational Guidelines for Seniors’ Mental Health: TheAssessment and Treatment of Delirium (CCSMH, 2006).

Despite the high prevalence of mental disorders, studieshave demonstrated limited availability of psychiatric andmental health services for residents living in CanadianLTC homes (Conn & Silver, 1998; Conn et al, 1992).

1.4 Principles and Assumptions Guiding theCare of Residents in LTC Homes

The recommendations in these Guidelines are based onprinciples and assumptions that should guide the carereceived by all residents in LTC homes. These principlesand assumptions are over-arching and will promote andsupport the mental health of all residents, whether ornot they have mental health problems (including mentaldisorders).

Principles

The following principles should underpin the care-givingmilieu in LTC homes. They are consistent with other setsof principles developed through reiterative consultationwith older adults, family caregivers, volunteers, geriatric

specialists in psychiatry, health care professionals, andorganizations interested in elderly persons or those atrisk of mental health problems (AGS/AAGP, 2003;British Columbia Ministry of Health, 2002; RNAO,2004).

• Residents should receive care that is individualized,person-centred, and, to the extent desired and possible,self-directed.

• Families should be respected as part of the resident’songoing social support system and integrated withinthe LTC setting in mutually acceptable and supportiveroles.

• Care should reflect an integrated consideration of bio-logical, psychological and social needs. A biopsychoso-cial model expands the focus from individual patholo-gy to a consideration of the whole person, includingboth strengths and limitations, within the context oftheir social and physical environment.

• A culture of caring that includes principles of psy-chosocial rehabilitation to maximize quality of lifeshould be established. Psychosocial rehabilitationemphasizes the importance of involvement in develop-ing and realizing one’s own personal care and lifegoals. The need for health promotion and treatmentservices that assist residents to manage their symptomsand build on their strengths is integral to thisapproach.

• An increasingly supportive and assistive social andphysical environment, responsive to residents’ chang-ing needs, should be created to maintain function andcompensate for functional decline (e.g., in individualswith dementia). This includes shifting the primaryfocus from tasks to relationships.

• Preventative interventions, including strategies for main-taining wellness, and early interventions for mentalhealth problems and disorders, should be developed,implemented and incorporated into specific training pro-grams for both informal and formal caregivers.

• All staff, regardless of their discipline or role, should besupported in maintaining the knowledge and skillsnecessary to provide informed and competent care.

Assumptions

Facilities that provide LTC for seniors vary widely in size,appearance, resources and service models. What theyhave in common, however, is that they house combinedaccommodation and health care services for individualswho are unable to manage in a less supportive physicaland social environment. The following are assumptionsabout facility-based LTC that underpin these Guidelines.

Focus of Care: The main focus of care for persons in LTChomes should be on overall well-being and quality oflife, which includes addressing the needs of the individ-ual, even when those needs are not articulated as may bethe case in dementia and some mental disorders.


Thus, a core assumption of these Guidelines is that there isa need to focus on both mental health and mental illnessin the care of older adults who reside in LTC homes.

Diversity: Each resident is an individual, who deservesan individualized approach to care delivery. It isacknowledged that the target population encompasses aheterogeneous group of individuals, widely varied notonly in chronological age (65 to plus 100 years of age),but also in culture, ethnicity, race and sexual orientation.Given the state of knowledge, no attempt is made torefine recommendations as a function of populationsubgroups. While these specific issues are not discussedherein, it is assumed that care providers will identify spe-cial needs and make appropriate adaptations to theGuidelines where required.

Resources: Service delivery differs across the countrybased on differences in provincial/territorial legislation,and differences in access to resources (e.g., northern ver-sus southern geography, urban versus rural communi-ties). Therefore, the availability of health care profession-als and how they perform their work, of secondary andtertiary resources, and access to specialists varies. A coreassumption underlying these Guidelines is that effectivemental health promotion and management of mentalhealth problems, including mental disorders, requires aninterdisciplinary team effort. It is beyond the scope ofthese Guidelines to propose criteria for interdisciplinaryteam composition within LTC homes, or to address thechallenges of available resources. However, the centralityof this issue for the implementation of these best practicerecommendations is acknowledged.

Relationships: Many residents have ongoing relation-ships with family members and significant others. Theserelationships are critical in meeting the mental health

needs of residents and should be supported by interac-tions with facility personnel who communicate respectand visitor friendly policies (e.g., appropriate visitinghours, availability of beverages policy, etc.).

Family members and significant others should be sup-ported in finding mutually acceptable and beneficialways to participate in the care of their loved one.Participation can occur at different levels. For example,some family members may choose to be involved inhands on care (e.g., assisting at mealtime), while othersmay choose to participate in Family Councils which pro-vide feedback to the facility from a family perspectiveregarding care and services.

Some family members and others will require emotion-al support from staff. Acknowledgement of the individ-ual’s personal knowledge of a family member/significantother, and consulting and sharing information (asappropriate) communicates respect. More formal assis-tance and referrals for support should be made availablewhen necessary.

In addition, the interactions between residents and staffare of crucial importance in meeting the mental healthneeds of residents. For many residents, the care providersare their primary source for social and emotional con-tact. Interactions that are based on knowledge of eachresident’s individuality, that communicate respect,warmth, and care, will promote mental health.

Milieu: The LTC facility is a closed community, housinga unique population. A core assumption of theseGuidelines is that the milieu (social and physical envi-ronment) is an important determinant in psychosocialand health outcomes for residents in LTC homes, andcan promote or undermine mental health.


2.1 Introduction

In these Guidelines, we consider care for residents livingin LTC homes within two broad categories: 1) aspects ofactivities of daily living (ADL); and 2) symptom and dis-ease management. This section will focus on researchrelated to providing care to residents in the context ofADLs, such as physiological needs (i.e., eating, drinking,toileting and sleep), and hygiene. Subsequent sectionsaddress assessment and interventions focused on symp-tom management (depressive and behavioural symp-toms).

Respect for culture, equity, social justice, relationshipsand personal dignity is essential for promoting mentalhealth in LTC facilities (Government of Canada, 2005).Relationships, service-delivery models, management ofthe physical and social environment, and effective care-giving strategies are primary vehicles for mental healthpromotion for seniors who reside in LTC homes.

In order to create a culture that supports interventionsand care that is truly effective, the following tenets mustbe realized in practice: relating effectively, knowing theperson, recognizing retained abilities, and manipulatingthe social and physical environment (McGilton et al.,2006; RNAO, 2004).

Relating effectively to residents entails that the careprovider remain with the resident during the careepisode, alter the pace of care by recognizing the person’srhythm and adapting to it, and focus care beyond thetask (Brown, 1995; McGilton, 2004).

Excellence in care can be achieved when knowing theperson and their individual preferences, and constantlyevaluating and adapting to the person’s response, guidesall interactions/ interventions.

Knowing the person involves becoming familiar with theindividual and gaining knowledge of their life. At timesthis may involve partnering with families to gain thisknowledge. A persons’ unique identity will influencewhat activities/interventions are personally appealing orpleasant. As well, to know the person involves under-standing his/her culture, and how that person views andresponds to the world.

Care must also focus on recognizing the person’sretained abilities in self-care and the social, interactionaland interpretative domains. Recognition of retained abil-ities creates a basis for the prevention of excess disabilityand enhancing the success of the care intervention(Dawson et al., 1993). An assessment of a resident’sretained abilities will influence the amount of care thecare provider must deliver to compensate for functional

losses. The physical environment is an important consid-eration in this assessment as some settings are designedto compensate for waning abilities, while others exacer-bate the challenges (Teresi et al., 2000).

Although most research regarding provision of care in LTChomes has focused on those with dementia, we believe thatthe same tenets can/should be taken into considerationwhere physical and mental illnesses are the primary diag-noses that underlie the need for facility-based LTC.

Residents with physical and mental illnesses experience avariable constellation of symptoms, which include mem-ory loss, disorientation, reduced ability to perform activ-ities of daily living such as eating, bathing and dressing,as well as psychiatric and behavioural symptoms such asagitation, depression and psychosis (Qizilbash et al.,2002; Tilly & Reed, 2004).

Often non-verbal behaviours, such as agitation, restlessness,aggression and combativeness, are an expression of unmetneeds (e.g., hunger, thirst, pain, or toileting need). Careproviders should try to identify when this is the case andaddress the unmet needs. The general care recommenda-tions presented herein focus on preventing and minimizingbehavioural symptoms that are a reflection of unmet needs.These recommendations are offered with the caveat thatcareful attention to assessing and understanding the factorscontributing to behavioural presentations, (e.g., mentalhealth problems and disorders, as well as other physical dis-orders and illnesses) is paramount.

The non-pharmacological care strategies included in thissection have been found to reduce behavioural symp-toms in residents. Successful implementation of theserecommendations involves a careful assessment ofremaining abilities and knowledge of the persons’ prefer-ences. The way in which the care provider relates to theresident when implementing the recommendations andthe care provider’s ability to manipulate the social andphysical environment as required, will enhance the pos-sibility of achieving the desired outcomes.

2.2 General Care:Discussion and Recommendations

This first recommendation provides an essential underpin-ning to all those that follow.

Recommendation: General Care – Family Involvement

Encourage and support the involvement and educa-tion of the family in the institutional life of the olderresident, including decision-making processes, asappropriate. [C]

Part 2: General Care


Families have been involved in the caregiving processthroughout history but it is only recently that practitionershave begun to recognize and formalize the role of the fam-ily in the context of healthcare (Byers, 1997). Family mem-bers often struggle with their change of roles after admis-sion of a relative. An evidence-based protocol for creatingpartnerships with family members has been created byKelley and colleagues (1999). Family involvement in carefor persons in LTC homes includes a program for familiesand caregivers in partnership with healthcare providers(Kelley et al., 1999). The ultimate goals of the protocol areto provide quality care for persons with dementia and toassist family members through support, education, and col-laboration, to enact meaningful and satisfactory care-givingroles regardless of setting.

Although most networks are comprised of family, friendsand neighbours also provide support. Further research isrequired to elicit definitive patterns of interaction,expand nurses’ understanding of client-family caregiver-nurse collaboration, and to facilitate optimal outcomesfor residents (Dalton, 2003).

Recommendation: General Care – Care Plan

Individualize care plans, with due consideration to bestpractice guidelines and recommendations. [D]

Best practice guidelines and recommendations, such asthose herein, provide a generic framework for developingcare plans that address a resident’s needs. We stress, how-ever, the importance of the individual, client centeredcare, respect for diversity, involvement of families, andthe centrality of care providers training and skill. Best practice recommendations should be implementedin light of personal information provided by residents sothat staff can develop and refine approaches to carebased on an understanding of the resident’s usual liferhythms, lifestyle, culture, and preferences. Suchapproaches are important in preventing behaviouralsymptoms that may result from fear, frustration or dis-ruption of continuity and familiarity. Pre-admissioninformation that includes medical history, social history,personal likes/dislikes, what is important to the resident,and history of behavioural symptoms and approaches used,should be available to LTC staff to optimize individualizedcare.

Staff should establish a relationship with an older resi-dent that reflects the older individual’s physiological,psychosocial, developmental, and spiritual needs. Staff,when presented with a social history (as compared toonly medical history), are able to maintain more neutral,appropriate attitudes towards challenging LTC facilityresidents (Hillman et al., 2001). This information is alsohelpful in understanding the genesis of problem behav-iours and developing alternative activities for residentswith dementia (Sloane & Gleason, 1999).

Anderson and colleagues (1998), in an examination of theinterventions used by aides working with aggressive resi-dents with dementia, noted that effective approaches werebased on the following four factors: the aides’ interperson-al experiences and values; attitudes; team work; and know-ing the residents. Based on these factors, the aides were ableto connect and provide individualized caring interventionsthat maintained safety, dignity and support.

Recommendation: General Care – Communication

Implement strategies to promote communicationbetween care providers and residents. [B]

To determine the need for strategies to promote commu-nication between care providers and residents:• Use the tools provided by the Hartford Institute for

Geriatric Nursing to assess language abilities (i.e.receptive and expressive abilities) (Frazier-Rios &Zembrzuski, 2004).

• Use the Interactional Abilities Assessment Guide byDawson and colleagues (1993) to assess the resident’scommunication abilities.

• Assess normal aging processing, such as hearing andvision loss, that affect residents’ ability to communi-cate effectively.

• Assess the resident’s language abilities and communi-cation patterns with assistance from family membersor significant others.

Care providers may use the following communicationstrategies. Consideration should be given to an individ-ual’s disease progression & retained abilities, as dis-cussed.• Care providers should identify themselves at each

interaction.• Residents may use personalized memory books con-

sisting of biographical, orientation cues and dailyschedule information. Books may contain pictures,instructions on bathing, and pages targeting behaviourproblems (Burgio et al., 2001).

• Care providers should use the following communica-tion tips: short simple sentences; speak slowly; ask onequestion or give one instruction at a time; approachthe resident slowly and from the front; establish andmaintain eye contact; eliminate distractions (TV,radio); avoid interrupting the resident and allow theresident plenty of time to respond; use “yes/no” ratherthan open ended questions; encourage circumlocution(ask resident to “talk around” or search the wordhe/she is looking for); repeat messages using the samewording; and paraphrase repeated messages (Small etal., 2003).

• Supplement verbal communication with gestures orcues when possible.

• Listen to residents’ experiences and acknowledge theiremotions, while providing understanding and non-judgement of their choices.


• Use enhanced instruction, rehearsal and cueing whenresidents are unable to follow 3 step commands(Cohen-Mansfield, 2005).

• When verbally communicating with a resident,remember that how you relate to the resident, that is,with a calm tone and respect, will also influence thesuccess of the interaction (McGilton, 2004).

• When communication barriers exist, take responsibil-ity for developing a communication plan that makesthe resident an informed partner in the provision ofcare. The plan can include verbal and non-verbalapproaches.

• Interpreters can be very helpful in situations where alanguage barrier exits. When using interpreters tocommunicate with residents, care providers need tobe sensitive to the issues surrounding interpretation(i.e., the need for the interpreter to treat obtainedinformation as confidential and the need for theinterpreter to repeat everything the resident and thecare provider say, without omissions).

Cognitive and behavioural impairments in personswith dementia affect their ability to communicate. Theabove interventions aim to match care provider and res-ident conversation to the resident’s comprehensionlevel (Hall & Buckwalter, 1991).IV Burgener and col-leagues (1992) identified care providers’ behavioursassociated with dysfunctional elderly behaviour. Therewas a relationship between care providers who wererelaxed and smiled and seniors with calm and function-al behaviours. Use of memory books by persons withdementia has been found to increase informativenessand accuracy of their conversations, and decrease ambi-guity and restlessness (Bourgeois & Mason, 1996). Useof communication aids can compensate for cognitivedeclines and decrease disruptive behaviour and agita-tion. Communication training for care providersimproves communication behaviours and is sustainableover time when combined with a staff motivational sys-tem (Burgio et al., 2004).IIa

It is not hard to understand why residents who are notgetting their basic needs met might express their dis-comfort through behavioural symptoms. Priorities forfuture research should include exploring methods ofhelping residents improve their eating, drinking, dress-ing, bathing, toileting and sleeping patterns (Tilley &Reed, 2004). What is known in these areas is addressedbelow.

Researchers also need to focus on the process of imple-menting best evidence into practice. There is an absenceof research that conveys the processes of knowledgeexchange and utilization within the specific context ofLTC homes. It would be premature to apply the findingsof studies conducted in acute care settings with unregu-lated care providers until it has been established thatsuch translations are empirically sound.

Recommendation: General Care – Dressing

Develop an individualized approach when assistingthe resident with dressing. [B]

To determine what abilities are retained and which willneed support for each resident: • Assess all residents who have a diagnosis or suspected

diagnosis of dementia.• Assess residents’ retained abilities using a scale such as

the Abilities Assessment Instrument (AAI) (Dawson etal., 1998). The AAI assesses self-care, social, interac-tional, and interpretive abilities of the resident, whichwill influence their ability to participate in dressing.

Self care abilities threatened in the presence of dementiaand that will interfere with dressing include: voluntarymovement of the fingers and arms; spatial orientation,finding one’s way; initiation and follow-through relatedto object cues; and purposeful movements. Furthermore,abilities that are threatened in the presence of dementiahave been presented by Dawson and colleagues (1993)IV

and relate to self-care, social, interaction and interpretivedomains.

Specific dressing assistance interventions will depend onthe retained abilities and may include:• Provision of appropriate cues, such as left/right verbal

cues. For example, while dressing, ask the client toplace his/her right foot in the shoe.

• Presenting clothing in sequential order enhances resi-dents’ independence (Day et al., 2000).III

• Avoid stimulation of primitive reflexes, for example,the grasp reflex.

• When assisting with dressing, offer one-step instruc-tions.

• If possible, stand the person to prosthetically use grav-itational force to extend the residents’ fingers in orderto ease putting on shirts, dresses, or jackets.

• Use task simplification to focus on abilities and assistwith performance of ADLs (Beck et al., 1997; Wells &Dawson, 2000).II

An effective intervention to increase active participationin ADLs and decrease disruptive behaviours in severelycognitively impaired and functionally disabled LTC facil-ity residents has been demonstrated (Rogers et al.,1999).IV The approach was based on knowledge of theresident and on detailed professional, functional andcommunication assessments. It was successful in reduc-ing disruptive behaviours (in spite of demandingincreased performance) because only realistic perform-ance demands were made and communicated in themode each particular resident could understand.

An abilities focused approach to care-giving may preventexcess disability from arising, thus preserving residents’


quality of life (Dawson et al., 1993).IV Residents receivingmorning care from care providers using an abilitiesfocused approach demonstrated increased interactionbehaviours with care providers, decreased levels of agita-tion, and a higher level of function (Wells & Dawson,2000).II

Recommendation: General Care – Bathing

Develop an individualized protocol for each residentthat minimizes negative affect and promotes a senseof well being during bathing. [A]

All individuals residing in LTC homes can benefit from abathing intervention. To reduce agitation, irritability, andanxiety, consider the following interventions whilebathing residents:• Cover the resident with a towel to maintain warmth

and privacy (Sloane et al., 2004).• Provide the resident with choices.• Use products recommended by family.• Use no rinse soap (Sloane et al., 2004).• Modify the shower spray.• Provide the resident with information before and dur-

ing the bath (Mickus et al., 2002).• Reassure the resident that he/she is safe and not alone

(Mickus et al., 2002).• Begin bathing the least sensitive area first and save

washing hair for last.• Use distraction techniques (e.g., calming music,

singing, talking, food or sweets).• Follow bathing with a light massage with lotion.• Document bathing practices accepted by the resident

in the care plan so other care providers will follow thesame routine.

• Frequency of behaviours may be reduced duringbathing when residents listen to their favorite music(Clark et al., 1998).

Bathing care using a person-centered approach is asso-ciated with a decrease in agitation and other behaviour-al responses (Sloane et al., 2004).Ib The potential forbathing to be a calming and relaxing intervention withthe ability to derive a feeling of well being, in additionto personal hygiene and infection control, is supportedin the literature (Sloane at al., 2004).Ib Bathing alsoinvolves multiple stressors to which agitation and otherbehavioural symptoms are normal responses (SchindelMartin, 1998 as cited in Thiru-Chelvam, 2004).Reactions occur because of perceived threat, unfamiliaractivities, recall of previous trauma, unpleasant sensa-tions (hot/cold), feeling confused, misinterpretation ofstaff as being harmful or not helpful, unwanted touchor invasion of personal space, frustration from declin-ing abilities, and/or lack of attention to personal needs(Thiru-Chelvam, 2004). Using a bathing techniqueguided by privacy, reassurance, information, distraction,and evaluation reduces irritability and anxiety (Mickuset al., 2002).III

Recommendation: General Care – Activities

Consider the need to pace activities that residents areinvolved in throughout the day. [B]

To determine which residents are likely to benefit fromactivity pacing:• Assess cognitive dysfunction with a validated tool such

as the mini-mental status examination (MMSE)(Kovach et al., 2004). Pacing of care-giving activities iseffective with persons who have mild to moderatedementia, as determined by the MMSE (Kovach et al.,2004).

• Measure arousal and agitation every 15 minutes from8:00 am to 8:00 pm on one day (Kovach et al., 2004).

• Measurement should not be collected on a day whenpotentially confounding events occur. For examplebath days, monthly doctor visit days, and days inwhich a test or exam is scheduled.

• Residents are considered to have an arousal imbalanceif the daily activity schedule involves an awake arousalstate that is sustained for longer then 1.5 hours. Thisdefinition is based on two pilot studies, one based in aLTC setting and one in an acute care setting (Kovach &Schlidt, 2001; Kovach & Wells, 2002).

• Substantial arousal imbalance involves arousal statesof 2.5 hours or more.

Once a resident is recognized as having periods of arous-al imbalance, specific periods of imbalance between sen-sory-stimulating and sensory-calming activities can beidentified. Interventions may include arranging a newdaily activity schedule that:• Contains fewer periods of arousal imbalance (ideally

none). This may involve the need to add or deletesome activities from the resident’s schedule.

• Is feasible considering the resident’s needs and prefer-ences

After implementing the new activity schedule, the resi-dent’s arousal and agitation state should be assessedevery 15 minutes for 12 hours.

Pacing activities decreases agitation and supports sensoris-tasis (an optimal level of sensory variation) in persons withdementia (Kovach et al, 2004),IIa and has the potential toreduce agitation and other behaviours in all LTC residents.An overwhelming influx of external stimuli and lack ofphysical and social environmental stimuli are both risk fac-tors for agitation in persons with Alzheimer’s Disease andRelated Disorders (McGonigal-Kenney & Schutte, 2004).IIa

Recommendation: General Care - Mealtime

Consider the need to develop mealtime care-givingactivities to enhance nutrition and prevent behavioursthat interfere with nutritional and social needs. [D]


To determine which residents are likely to benefit frommealtime care-giving activities:• Assess residents’ ability to initiate sequence and follow

through with complex or simple actions and the abili-ty to use tools.

• These abilities can be reliably assessed using theFeeding Abilities Assessment (FAI) (LeClerc et al.,2004).IIa

• Administer the FAI during the resident’s usual meal-time and location.

• Assess vision, hearing and oral health.• Assess changes in medications that may alter taste.• Assess for adequate pain management.

Interventions may include:• Keeping dining area quiet and small, with activity at a

minimum.• Keep lighting high without glare.• Food presentation is important. Food needs to be

appealing, easily identified, look and smell good. Donot serve pureed food to residents who can managefinger foods (Wells & Dawson, 2000).

• Open cartons, unwrap food, and remove bones.• Dishes should be of contrasting colors and stand out

from the table/tablecloth.• Cut food prior to serving.• Cue resident manually (Roberts & Durnbaugh, 2002).• Space residents away from others.

• Cue and re-cue resident to pace eating, and to chewfood (Roberts & Durnbaugh, 2002).

• Remove nonfood items.• Promoting social stimulation at meal times, including

familiar tablemates (Roberts & Durnbaugh, 2002).• Check toileting needs before bringing resident to din-

ing room or feeding.• Offer alternatives.• Alter diet consistency.• Use calming music.

Feeding interventions increase the potential that resi-dents will be as independent as possible, move towardsgoals that reduce excess disability, and enhance residentabilities (Roberts & Durnbaugh, 2002).III Malnutrition isa common challenge for LTC residents. Those with cog-nitive impairment are at the highest risk. In residentswith Alzheimer’s disease, challenging mealtime behav-iour can interfere with successful self-feeding (Roberts &Durnbaugh, 2002).III Appropriate mealtime assessmentand correct, consistent staff intervention can address thesuccess of the individual resident’s ability to eat inde-pendently, thus enhancing quality of life (Roberts &Durnbaugh, 2002).III A common correlation existsbetween malnutrition and dementia (Watson, 1989).Inadequate pain management may contribute to agita-tion, inability to concentrate on the task, and not want-ing to eat.


3.1 Introduction:

This section of the Guidelines provides recommenda-tions for the assessment of depressive and behaviouralsymptoms that represent mental health problems andmental disorders. The clinical activities of formal assess-ment and treatment should occur within the context ofthe principles, assumptions, and general care-giving rec-ommendations described in Part 1: BackgroundInformation and Part 2: General Care.

For the purpose of this guideline, assessment is under-stood as a comprehensive, ongoing process thatincludes: (1) screening to detect depressive and behav-ioural symptoms; (2) structured, goal-directed investi-gation to identify factors precipitating, maintaining andexacerbating identified symptoms; (3) interpretation ofassessment findings, including formal diagnosis whereappropriate; and (4) ongoing evaluation of clinical out-comes and treatment effectiveness to determine theneed for reassessment and re-conceptualization of con-tributing factors.

Assessment protocols are understood as problem-orient-ed frameworks that guide thinking about an issue.Protocols structure the decision-making process so thatthe assessment process is efficient, yet comprehensiveenough to lead to an appropriate care plan for an indi-vidual resident. The interRAI suite of tools (including theMinimum Data Set [MDS]) provides an example of aresearch-based, standardized approach to the develop-ment of an assessment protocol (Morris et al., 1995).

In this section, it is assumed that a facility adheres to anoverarching assessment protocol or model, as opposed toallowing assessment activities to occur on an ad hoc,inconsistent basis. The recommendations speak to therecommended components of the assessment protocol.It is recognized that implementation of an assessmentprotocol in any given instance should be client-centredand clinically sound. It is also recognized that the assess-ment protocol must be integrated with both site-specificpolicies and statutory requirements. Levels of staffing,skill mix and credentials necessary to implement aneffective assessment protocol are beyond the scope ofthese recommendations. However, their importance isacknowledged herein, as in other guidelines (AGS/AAGP,2003; RNAO, 2003).

These recommendations specifically refer to assessment ofbehavioural and depressive symptoms in the context of LTChomes. The reader is also referred to the companion guide-lines, National Guidelines for Seniors’ Mental Health:Assessment and Treatment of Depression, Assessment andTreatment of Delirium, and The Assessment of Suicide Risk andPrevention of Suicide (CCSMH, 2006).

3.2 Assessment: Discussion andRecommendations

Recommendation: Assessment – Screening

The facility’s assessment protocol should specify thatscreening for depressive and behavioural symptomswill occur both in the early post-admission phaseand subsequently, at regular intervals, as well as inresponse to significant change. [C]

The purpose of screening is to detect symptoms that war-rant further detailed investigation, as well as to furtherprevention efforts.

The relative cost/benefits of different timelines for initialand repeat screening activities have not been establishedempirically. However, there is an emerging consensus inthe clinical practice literature on the importance of bothinitial screening in the early post-admission phase andsubsequently, repeat screening at regular intervals, aswell as in response to significant change. The AmericanMedical Directors Association (AMDA) (2003) depres-sion guidelines recommend formal screening on admis-sion and subsequently in response to significant change.The American Geriatrics Society and AmericanAssociation of Geriatric Psychiatry (AGS/AAGP) (2003)guidelines on depressive and behavioural symptoms, rec-ommend that residents should be screened for depres-sive symptoms in the first four to six weeks post admis-sion to a LTC facility, and subsequently at least every sixmonths. The MDS protocol, which includes depressiveand behavioural symptoms, prescribes initial screeningduring the first two weeks post admission, quarterly re-assessment, and ad hoc screening in response to signifi-cant change (Morris et al., 1995).

We believe that assessments for residents in LTC homesshould occur as soon as possible after admission.Furthermore, serial assessments of cognitive symptomsover time are recommended as they may indicate the effi-cacy of interventions, or changing medical conditions(APA, 2000a; McCusker et al., 2003; Rapp, 1998).II

Continuous monitoring and evaluation of interventionswill enable the team to respond appropriately to thechanging needs of the resident, and to adjust interven-tions accordingly.

Screening Tools and Scales


A variety of screening tools that are appropriate tothe setting and resident population should be avail-able to facilitate the screening process. [D]

Part 3: Assessment of Mental Health Problems and Mental Disorders


LTC homes should make available a selection of symp-tom rating scales that are appropriately matched to thecharacteristics of the residents, setting characteristics, andthe facility’s resources.

Screening tools to detect depressive symptoms include: • Geriatric Depression Scale (GDS) (Yesavage et al.,

1982-3)• Cornell Scale for Depression in Dementia (CSDD)

(Alexopoulous et al., 1988)• Centre for Epidemiological Studies of Depression Scale

(CES-D) (Radloff, 1977)• Minimum Data Set (MDS) (Morris et al., 1995).

The GDS and CES-D are self-report scales, while theCSDD and MDS rely on proxy report. Differences in bothadministration (self- versus proxy-report) and the con-structs measured by each scale may contribute to differ-ent findings obtained with various scales. For example, arecent comparison between the GDS and MDS amongnursing home residents found these scales were uncorre-lated, however each measure demonstrated adequateinternal consistency and reliability (Koehler et al.,2005).III More research is needed on the profiles ofdepression in LTC residents, and which aspects of depres-sion are best measured by which scales.

Standardized scales for the screening of behaviouralsymptoms in residents within LTC homes include: • Brief Agitation Rating Scale (BARS) (Finkel et al.,

1993)• Cohen-Mansfield Agitation Inventory (CMAI) (Cohen-

Mansfield and Billig, 1986)• Minimum Data Set (MDS) (Morris et al., 1995).

As well, numerous behavioural rating scales have beendesigned specifically for use with residents who havedementia (for recent reviews, see Hemels et al., 2001;Hyer et al., 2005): These include, for example: • Behaviour Pathology in Alzheimer’s Disease Rating Scale

(BEHAVE-AD) (Reisberg et al., 1987).• Behavioural Symptoms Scale for Dementia (BSSD)

(Devand et al., 1992)• Neuropsychiatric Inventory (NPI) (Cummings et al.,

1994)• Pittsburgh Agitation Scale (PAS) (Rosen et al., 1994).

Behavioural scales, like scales to measure depressivesymptoms, also include different combinations ofbehaviours and use different metrics to quantify frequen-cy, duration and severity. Many require trained raters andas of yet, there is no “gold standard” (Teri et al., 2005).


Tool selection should be determined by the charac-teristics of the situation (e.g., resident capacity forself-report, nature of the presenting problem). [D]

Screening tools should be selected on the basis of clini-cal utility. It may not be appropriate to attempt to use aself-report tool with a resident who is confused or non-verbal. Conversely, it is not appropriate to omit self-report for reasons of expedience.

Clinical situations may require, in addition to or inplace of standardized scales, the use of customizedbehavioural observation techniques to adequately screenfor atypical or complex behaviours. It is beyond thescope of these Guidelines to review the extensive field ofbehaviour observation and analysis (often referred to“ABC” for Antecedents-Behaviour-Consequences) indetail. However, it is acknowledged that this is a well-established approach to behaviour assessment in a vari-ety of settings, including LTC homes that should be with-in the armamentarium of the interdisciplinary team (forexample see, Gibson et al., 1999; Lundervold & Lewin,1992; Rewilak, 2001).

The screening protocol should endorse use of more thanone measure (e.g., self-report and proxy-report, as well asbehavioural observation) where this information would behelpful in meeting the purpose of the screening assessment(i.e., to detect symptoms that warrant further detailed inves-tigation, as well as to further prevention efforts).


Screening should trigger detailed investigation ofdepressive and behavioural symptoms under definedcircumstances. [D]

Screening should trigger implementation of a structured,goal-directed detailed investigation of depressive andbehavioural symptoms under defined circumstances.Triggering algorithms are empirically grounded in thecase of protocols such as the MDS (Morris et al., 1995).The AMDA (2003) depression guidelines describe a clin-ical-decision making process based on risk assessmentfor determining when symptom monitoring versus activeinvestigation is indicated. The assessment protocolshould include a triggering/decision-making algorithmto guide clinicians in determining when further detailedinvestigation is required.

Recommendation: Assessment – Detailed Investigation

Core elements of a detailed investigation shouldinclude history and physical exam, with follow uplaboratory and psychological investigations, investi-gations of the social and physical environment, anddiagnostic tests as indicated by the results of the his-tory and physical exam, and treatment history andresponse. [C]

The purpose of the detailed investigation is to identifyfactors, including diagnosable conditions, that precipi-


tate, maintain and exacerbate identified symptoms, inthe interests of symptom management, disease control,enhanced quality of life, and/or problem prevention.

The detailed investigation should be premised on anunderstanding that symptoms may reflect a variety ofunderlying biopsychosocial conditions and social andphysical environmental issues, and should take intoaccount strengths and protective factors as well as prob-lems. There is no definitive research literature on howbest to structure the detailed investigation of behaviour-al and depressive symptoms in the LTC setting as a cost-effective, integrated, interdisciplinary, goal-directed activ-ity (Hyer et al., 2005).

Clinical practice guidelines identify several of the factorsthat can contribute to the onset or worsening of depres-sive or behavioural symptoms, and as such the followingshould be included as core elements in the investigationprotocol (AGS/AAGP, 2003; AMDA 2003)III:• History (including a formal ABC analysis of the

antecedents and consequences of target behaviourswhere appropriate)

• Physical exam• Follow up investigations as indicated by the findings of

the history and physical exam• Follow up investigations may include laboratory tests,

psychological assessments, investigations of the socialand/or physical environment and diagnostic tests

• Treatment history and response

Other factors hypothesized to contribute to theobserved symptoms should also be included in theinvestigation. Flexibility and clinical judgment arerequired as these factors will vary on a case-by casebasis. Behavioural observations, self-report data, con-cerns expressed by others and psychometric data shoulddirect the assessment focus. However, a high index ofsuspicion should be maintained to ensure less obvious fac-tors or diagnoses that are contributing to the precipita-tion, maintenance and exacerbation of depressive andbehavioural symptoms are not missed. Among the med-ical and psychological conditions and disorders thatmay need to be included in the detailed investigationare (AGS/AAGP, 2003):• Pain • Constipation or fecal impaction • Infections • Injury • Dehydration• Nutritional problems • Delirium • Dementia• Psychosis • Depression/Mania • Suicide Risk (refer to the National Guidelines for Seniors’

Mental Health: The Assessment of Suicide Risk andPrevention of Suicide, CCSMH 2006)

• Anxiety disorders • Sleep disorders • Substance or medication abuse or withdrawal• Hearing and vision problems • Worsening of chronic medical conditions • Recent onset of new medical condition • Medications that have the potential to alter cognition

or mood

Social factors and features of the physical environmentthat may need to be assessed include:• Changes in social or family situation • New stressors or situational factors such as changes in

staff • Availability of social and meaningful activities• Availability of positive (reinforcing) experiences• Deviations from normal life patterns, preferences, and

autonomy• Factors in the physical environment, such as a change

in room


It is important to consider all contributing factors.Investigation of potentially contributing factors (e.g.,delirium, chronic pain) should refer to clinical prac-tice guidelines for these conditions where available.[D]

Where available, investigation of potentially-contribut-ing factors should refer to clinical practice guidelines forspecific conditions. For example, where pain is suspectedas a contributing factor, clinical practice guidelines onpain assessment should guide assessment (e.g., AGS,2002; AMDA, 1999). If delirium is suspected refer to theNational Guidelines for Seniors’ Mental Health: TheAssessment and Treatment of Delirium (CCSMH 2006).


Diagnosis and differential diagnosis should be anassessment objective where appropriate. [D]

Diagnosis and differential diagnosis should be an assess-ment objective where appropriate (AMDA, 2003).IV

Depressive and behavioural symptoms may reflect psy-chiatric diagnoses commonly seen in residents of LTChomes (e.g., dementia, delirium, depression, mania, dys-thymia, insomnia, anxiety, schizophrenia, personalitydisorders) and/or medical diagnoses that are also com-mon in this population (e.g., diabetes, respiratory dis-eases, arthritic and rheumatic diseases, cardiac disorders,stroke, chronic pain disorders). Assessment should beguided by awareness and understanding of relevant diag-nostic criteria (for example, the DSM IV-TR criteria differ-entiates major depressive disorder, adjustment disorderwith depressed mood, or mood disorder due to a gener-al medical condition; APA, 2000a).


It is acknowledged that depressive symptom presenta-tion in older adults may be atypical, subsyndromal ordifficult to distinguish from other comorbid conditions.It is important to realize that it may be difficult to deter-mine the exact cause of depressive and behaviouralsymptoms, especially in situations involving complexcomorbidity or atypical presentations (Lo & Bhanji,2005). Behavioural analysis (ABC) can be particularlyuseful as an assessment tool leading to case conceptual-ization (rather than formal diagnosis) in these complexsituations.


The end point of a detailed investigation should bethe determination of the need for, type, and intensi-ty of treatment. [D]

The end point of a detailed investigation is the determi-nation of the need for, type, and intensity of treatment.The assessment protocol should explicitly include expec-tations for data synthesis and interpretation. It is notbeneficial to overemphasize the measurement aspects ofthe assessment process, while short-changing data analy-sis, synthesis and interpretation (AGS/AAGP, 2003). Theneed for, type, and intensity of treatment is determinedon the basis of consideration of all relevant assessmentinformation. This includes medical and physical find-ings, psychosocial findings, ratings on validated scales,behavioural analysis, risk assessment, formal diagnosiswhere appropriate, and the perspectives and wishes ofindividual residents and their families.

As a component of determining the need for treatment, itis important that all residents with significant depressivesymptoms are assessed for suicide risk (refer to TheNational Guidelines for Seniors’ Mental Health: TheAssessment of Suicide Risk and Prevention of Suicide,CCSMH 2006).

It is beyond the scope of these Guidelines to propose cri-teria for interdisciplinary team composition within LTChomes that will ensure the appropriate skill set for com-prehensive assessment, or to address the challenges ofresource availability. However, the centrality of this issuefor implementation of these best practice recommenda-tions is acknowledged.

Recommendation: Assessment – Ongoing Evaluation

The treatment plan should specify the timeline andprocedure for ongoing evaluation of clinical out-comes and treatment effectiveness. [D]

The treatment plan should mandate ongoing evaluation ofclinical outcomes and treatment effectiveness. Ongoingevaluation is essential in the LTC setting, given the frailty ofthe population, high prevalence of comorbid conditions,and potential for rapid decline when symptoms escalate. Aswell, ongoing evaluation is essential to ensure interventionobjectives stay current with client-centred goals.


Ongoing evaluation should include history andassessment of change in the target symptoms. [D]

Assessment of the effectiveness of pharmacological andnonpharmalogical treatment for depressive and behav-ioural symptoms should include history and assessmentof change in the target symptoms (AGS/AAGP, 2003).IV


Assessment of change should include quantification,preferably with the same tool that was used pre-intervention. [D]

Assessment of the effectiveness of pharmacological andnonpharmacological treatment for depressive and behav-ioural symptoms should include the same instrument(s)used for initial screening/assessment (AGS/AAGP, 2003).IV


Unexpected clinical outcomes and treatment effectsshould trigger re-assessment and potentially re-con-ceptualization of the factors precipitating, maintain-ing and exacerbating depressive and behaviouralsymptoms. Potential adverse reactions to treatmentshould be evaluated. [D]

We believe that unexpected clinical outcomes, includingpotential adverse reactions to treatment, and treatmenteffects that are less than expected should trigger re-assess-ment and potentially re-conceptualization of the factorsprecipitating, maintaining and exacerbating depressiveand behavioural symptoms.

There is a need for more clinical research on depressive andbehavioural symptoms in LTC settings, and to identify vari-ous profiles and symptom constellations that warrant dif-ferent intervention and prevention efforts (AGS/AAGP,2003). Research on the expected trajectories of change,where different combinations of factors contribute to differ-ent symptom profiles and where different treatments areimplemented, would advance our ability to match residentsto interventions in the LTC setting.


4.1 Introduction

We emphasize that we are aware that LTC homes differ intheir resources, and that residents differ in the extent towhich family and friends are available and willing to beinvolved in care. This section takes an aspirationalapproach to the task of identifying psychological andsocial interventions that can contribute to the treatmentof depressive symptoms of residents in LTC homes, rec-ognizing that the reality of what is available may differ.It is always important to consider the potential benefitof both nonpharmacological and pharmacological inter-ventions.

4.2 General Treatment Planning:Discussion and Recommendations

The reader is directed to the companion NationalGuidelines for Seniors’ Mental Health: The Assessment andTreatment of Depression (CCSMH 2006), as a supplementto this section.

Recommendation: Depressive Symptoms:General Treatment Planning

Consider type and severity of depression in develop-ing a treatment plan. [B]

Guideline developers have identified several factors thatshould guide treatment decisions: severity, persistence ofsymptoms, previous history, patient/family preferences,and coexisting medical conditions (AGS/AAGP, 2003;AMDA, 2003; APA, 2000b; Baldwin & Wild, 2004;National Advisory Committee on Health and Disability,1996; RNAO, 2004, 2003). Treatment decisions are madeboth in the development of the treatment plan and on anongoing basis as a component of response monitoring.

The AGS/AAGP (2003) guidelines indicate that agree-ment has not been reached regarding the use of pharma-cological or nonpharmacological treatment alone for res-idents with major depression. As a result, their recom-mendation was that both modalities should beemployed simultaneously as the first-line treatment.Other guidelines state that in addition to this combinedapproach, either treatment modality can be used aloneto treat mild nonpsychotic major depression (Alexopouloset al., 2001; AMDA, 2003). Thus, the AMDA (2003)guidelines suggest that for less severe forms of majordepression, a single treatment modality can be a treat-ment of choice. The AMDA (2003) guidelines also indi-cate when the combined approach might be desirable.For example, it is suggested that patients with low self-esteem may benefit more from the combined approachthan from a single treatment modality (AMDA, 2003).Concerning more severe major depression, use of pharma-

cological treatment concurrently with psychotherapyseems to be a preferred treatment choice (Reynolds et al.,1999; Thompson et al., 2001).

In all cases, it is important to obtain a history of bipolarillness as the treatment of bipolar depression will likelyrequire the use of a mood stabilizer (see Section 4.4,Pharmacological Interventions). Psychotic symptoms asso-ciated with depression rarely respond to antidepressantmedication alone and usually require the addition of anantipsychotic medication.

Key recommendations from other guidelines that haveinformed the present process are summarized belowwith respect to treatment of major and minor depressivedisorder, as defined by DSM IV-TR (APA, 2000a).

For residents who have a MINOR depressive disorder:• Observation of the residents for up to 2 months with-

out specific treatment may be appropriate (AGS/AAGP,2003).IV

• The length of the observational period may range from2 weeks to 2 months, but not more than 2 months(AGS/AAGP, 2003; AMDA, 2003).IV (Note: We believethat psychosocial interventions to promote quality oflife should continued to be provided during the mon-itoring period)

• Alternatives for treatment include psychosocial inter-ventions (e.g., education, participating in socialevents), psychotherapy, and pharmacological interven-tions (AGS/AAGP, 2003; AMDA, 2003).IV

• Treatment choice depends upon factors such as severi-ty, previous history, persistence of symptoms, andpatient or family preference (AGS/AAGP, 2003).IV

• First-line treatment for residents with minor depres-sion includes psychosocial interventions and psy-chotherapy (AGS/AAGP, 2003; Alexopoulos et al.,2001).IV

For residents who have a MAJOR depressive disorder:• Psychosocial interventions, psychotherapy, pharmaco-

logical interventions with or without psychotherapyare effective in treatment of mild nonpsychotic majordepression (AGS/AAGP, 2003; AMDA, 2003; RNAO,2004).Ib

• Pharmacological interventions plus psychotherapy,ECT and pharmacological interventions are treatmentmodalities for severe nonpsychotic major depression(AMDA, 2003).

4.3 Psychological and SocialInterventions: Discussion andRecommendations

The psychosocial and social interventions described inthis section are grouped based on the effects or goals

Part 4: Treatment of Depressive Symptoms and Disorders


they hope to achieve. This approach reflects recentunderstanding that “common factors” underlie variousinterventions, and a focus on these might be the beststrategy for further development in this field (Niederehe,2005). Given the complexity and uniqueness of LTC set-tings, we have included interventions that would bedelivered by mental health clinicians, as well as othercare providers, family, and volunteers.

This review is not limited to those studies that had someelements of randomization. It is encouraging to see thatthere have been some recent, methodologically moresophisticated studies indicating efficacy of psychosocial andsocial interventions. However, the number of studies is stillvery small with non-cumulative findings, which, in turn,impacted our ratings of the recommendations.

Interventions are often multifaceted and integrate sever-al different strategies. For example, an active treatmentgroup might have received a treatment consisting ofsocialization, individualized activity, and participationin pleasant events. Consequently, it is difficult to deter-mine the treatment’s active ingredients. On the otherhand, Teri and colleagues (2005) have argued that inter-ventions in LTC settings should be multimodal in orderto address the progressive deterioration of function andcomplexity of problems in LTC residents.

Recently, there have been several attempts to developmultimodal and manual-based treatments for depres-sion and dementia in LTC settings. For example,Carpenter and colleagues (2002) reported a small sam-ple, pilot study in which they tested a new model forbrief individual psychotherapy with the goals to restore,empower and mobilize depressed LTC residents withmild to moderate dementia. Their approach integratedthe elements of humanistic and cognitive therapies witha consideration of the role that the LTC milieu can playin the onset of depression. Hyer and colleagues (2005)have noted that this might be a direction in which thedevelopment of psychosocial and social interventionswill proceed in the future.

Recommendation: Depressive Symptoms:Psychological and Social Interventions

Social contact interventions, including interventionsthat promote one’s sense of meaning, should be con-sidered where the goal is to reduce depressive symp-toms. [C]

Social contact interventions are interventions that exposeLTC residents to elements in the social environment,including family, paraprofessionals, and staff. The pur-pose of the intervention is to improve mood in personswith depression by providing an increased sense of mas-tery over the social and physical environment anddecreasing social isolation (Kasl-Godley & Gatz, 2000).

Interactions can be in-vivo and simulated. For example,weekly visits (for 24 weeks) by a volunteer and a nursewere associated with a significant decrease in depression(McCurren et al., 1999).Ib Playing a family member’srecording of the resident’s best-loved memories over thetelephone was associated with significantly increasedinterest in people and activities and decrease in sadmoods (Camberg et al., 1999).Ib In addition, providingsupport by facilitating affective expression, helpingpatients to feel understood, offering empathy and suc-cess experiences, and imparting optimism may be effec-tive in treating depressed LTC residents (Alexopoulos etal., 2003; AMDA, 2003).IV

The following social contact interventions can be used inthe treatment of depression:• Provision of meaningful activities, such as sheltered

workshops, volunteering, spiritual care, or activitiesthat maintain residents’ past roles (AGS/AAGP, 2003:Minor depressionIV; Major depression)Ib

• Supervised peer volunteer programs (AGS/AAGP,2003: Minor depressionIV; Major depression)Ib

• Simulated presence (Camberg et al., 1999)Ib

• Supportive therapy (Alexopoulos et al., 2003; AMDA,2003)IV


Structured recreational activities should be consid-ered where the goal is to engage the resident. [C]

A variety of recreational activities, with care providers’participation or supervision, appear to be associatedwith a decrease in depression and an increase in activitylevels.

Engaging LTC residents in individualized, recreationalactivities can have positive short-term effects. Long termeffects are less clear at this point. Interventions are usual-ly multimodal and combine either the recreational andsocialization components (Buettner & Fitzsimmons,2002; Rosen et al., 1997) or recreational and skill train-ing elements (Teri et al., 2003).Ib If these activities are tobe implemented by family members or other careproviders, it is important that they receive skill trainingin behavioural strategies that would target potentialproblem behaviours that might arise with increasedactivity (Teri et al., 2005).IV Studies showing positiveresults had interventions in place for at least threemonths, with care providers delivering or supportinginterventions on a daily basis.

The following activities have been suggested: • Intensive two-week wheelchair-biking in tandem

(Buettner & Fitzsimmons, 2002; Fitzsimmons 2001;University of Iowa Gerontological Nursing Interven-tions Research Center, 2003)Ib


• Variety of recreational activities selected according toeach resident’s choice (Rosen et al., 1997)Ib

• Care provider supervised exercise program (Teri et al.,2003)Ib


Psychotherapies should be considered where thegoal is to reduce depressive symptoms. [B]

There is some evidence for the effectiveness of the fol-lowing psychotherapies as a component of treatment ofdepressive symptoms in LTC residents:• Behavioural therapy (Lichtenberg, 1998)Ib

• Group cognitive-behaviour therapy (AGS/ AAGP, 2003;Hyer et al., 2002)Ib

• Individual cognitive-behaviour therapy (AGS/ AAGP,2003)IV

• Interpersonal therapy (Hinrichsen, 1999)IV

• Problem-solving therapy (Alexopoulos et al., 2003;Hussian & Lawrence, 1981)Ib

• Brief dynamic psychotherapy

The research literature on the use of specialized psy-chotherapies in LTC is fairly sparse, but encouraging.What is common across the studies is that participantswere selected according to their depressive symptomsrather than on the basis of clearly identified psychiatricsyndromes. Evidence for behavioural therapy, group cog-nitive-behavioural therapy and problem solving therapycomes from several studies, all of which had some ele-ments of randomization. Individual cognitive-behav-ioural therapy, interpersonal therapy, and brief dynamictherapy have not been subjected to empirical evaluationin LTC settings (visit the National Guidelines for Seniors’Mental Health, The Assessment and Treatment of Depression(CCSMH 2006) for more detailed descriptions of theseinterventions). Given the encouraging results regardingtheir use in treatment of late-life depression, we supportthe use of these therapies in LTC settings. The adaptationof these therapies to LTC settings rests on the assumptionthat they will be administered by clinicians sensitized tothe vulnerabilities and frailties of LTC residents(Niederehe, 2005).IV

Currently, there is very little data to guide clinicians intheir treatment decisions. One study demonstrated thatproblem-solving therapy (PST) might be a suitable therapyfor depressed older adults with impairment in executivefunctions (i.e., lack of interest in activities, psychomotorretardation, reduced insight, suspiciousness, and signif-icant behavioural disability; Alexopoulos et al., 2003).It has been noted that impairment in executive func-tions can increase the risk of a poor and unstableresponse in older adults to a variety of antidepressantsfor major depression (e.g., Alexopoulos et al., 2000). Itis encouraging that PST therapy can reduce depressive

symptoms in this patient population. Further researchis needed to replicate Alexopoulos and colleagues’(2000) finding. In this study, PST had several therapeu-tic ingredients:• Teaching skills for improving ability to deal with spe-

cific everyday problems and life crises• Exposure to positive events• Addressing interpersonal sensitivity• Addressing deficits in communication


Self-affirming interventions (e.g. validation and rem-iniscence therapies) should be considered where thegoal is to increase sense of self-worth and overallwell-being [C]

Validation and reminiscence therapies are examples ofself-affirming interventions. These two interventions canpotentially affect one’s sense of identity and general wellbeing in addition to remediating mood and behaviouralproblems.

Validation therapy is based on the general principle ofvalidation (i.e., the acceptance of the reality and person-al truth of another’s experience). Evidence regarding theefficacy of validation therapy is inconclusive. Variousobservational studies have reported some positive effectsof validation (e.g., increase in amount and duration ofinteractions during validation groups) (Babins et al.,1998; Bleathman & Morton, 1996), whereas othersreported null findings (Scanland & Emershaw, 1993). Ina recent meta-analytic review, it was noted that there wasinsufficient evidence from randomized trials to draw anyconclusions regarding validation therapy (Neal & Briggs,2003).Ia Some potential benefits that have been noted bythe proponents of this approach may be due to the extraattention given to individuals and/or participation instructured activities (Neal & Briggs, 2003). Futureresearch in this area should evaluate a wider range ofoutcomes, such as well being, quality of life, and itspotential beneficial effects for care providers utilizingthis approach.

Reminiscence therapy involves the discussion of pastactivities, events and/or experiences usually with the aidof prompts such as photographs, music, and other famil-iar items from the past. There is some evidence that rem-iniscence is effective in reducing depressive symptoms inolder people (Bohlmeijer et al., 2003).Ia There are severalforms of this therapy including, life review and generalreminiscence. Life review involves evaluation of personalmemories with the support of a therapeutic listener, usu-ally on a one-one basis. General reminiscence aims atenhancing positive, enjoyable interactions, usually in agroup context (Woods et al., 2005). There is some empir-ical support for the following interventions:


• Group reminiscence (Goldwasser et al. 1987)Ib (Jones,2003)IIb

• Individual reminiscence (Haight et al., 1998)Ib (Wang,2004)IIb

Comparisons across several studies conducted in LTC set-tings are difficult, partly because they explored varioustreatment modalities. The results are mainly encouragingand suggest that a more structured approach (e.g., indi-vidualized life review) may be more effective than open-ended recollection (Hyer et al., 2005).IV

4.3.1 Comorbid Dementia


Consider the impact of comorbid dementia in devel-oping a treatment plan. [C]

Given the high prevalence of comorbid dementia in theLTC population, the issue of treating depression in thiscontext warrants special consideration. We recommendthat explicit consideration be given to the impact ofcomorbid dementia in the implementation of psycho-logical and social interventions for the treatment ofdepressive symptoms in LTC residents. The resident’scapacity to understand and willingly engage in theintervention should be carefully considered in order toavoid unintended outcomes such as increased agitationor distress.

Professionals involved in the treatment of depressed LTCresidents who also have dementia, must adapt theirapproaches to fit the older person’s specific characteris-tics and living context (American PsychologicalAssociation, 2004). The progressive nature of dementiarequires a flexible approach to the treatment of depres-sion (Teri et al., 2005).IV For example, what works at acertain point for a particular resident might cease to beeffective as cognitive deterioration continues.

To effectively use non-pharmacological interventionswith people who have dementia, cognitive status, previ-ous experience with therapists, and the availability oftherapists have to be taken into consideration (AMDA,2003).IV Pre-existing rapport between a health-careprovider and a resident can be crucial in determining theefficacy of these interventions (AMDA, 2003).IV

In this section, we restricted our review to those studieswith a primary focus on depression in residents who alsohave dementia. Commonalities across these variousinterventions are: individualization of strategies, one-on-one treatment modality (with the exception of groupcognitive-behaviour therapy), multi-component charac-ter, and teaching care providers to provide treatment toLTC residents (Teri et al., 2005).

The following nonpharmacological interventions may beappropriate for treatment of depression for residentswith dementia. We stress that the appropriateness andeffectiveness of different interventions will vary for dif-ferent stages in the progression of dementia and individ-ualized assessment is essential. The reader is also referredto the best practices literature on dementia for a moreextensive consideration of psychological and social inter-ventions (e.g., Doody et al., 2001).

• Social Contact InterventionsSupportive therapy (AMDA, 2003)IV

Simulated presence (Camberg et al., 1999)Ib

• Structured Recreational ActivitiesRecreational biking (Buettner & Fitzsimmons, 2002)Ib

• Specialized TherapiesGroup cognitive-behavioural psychotherapy (AGS/AAGP, 2003)Ib

Individual cognitive-behavioural psychotherapy(AGS/AAGP, 2003; Scholey & Woods, 2003)IV

• Behavioural InterventionCare provider training in behavioural management(AMDA, 2003; Beck et al., 2002; Proctor et al., 1999)Ib

Care provider training in effective verbal and nonver-bal communication (McCallion et al., 1999)Ib

• Self-Affirming InterventionsReminiscence (Woods et al, 2005Ia; Brooker & Duce, 2000)III

Koder and colleagues (1996) indicated that an adaptedversion of cognitive-behaviour therapy for persons withdepression and dementia should include the followingcomponents:• Challenge the assumption “I am too old to change”• Greater emphasis on activities, behaviours and less on

cognitive restructuring• Provision of printed handouts, slower pace and a

greater reworking of issues• Group work• Attention to common themes of aging (e.g., low self-

esteem and anxiety about future)• Life-review and reminiscence• Involvement of significant others• Gradual termination and follow-up sessions

Scholey and Woods (2003) added other factors to thelist, such as an awareness of real social, economic andphysical limitations, a more flexible approach to sessiontiming, a more active role from the therapist, and consid-eration of ageism in therapy.

Woods and colleagues’ (2005) review of randomized trialsindicated some potential benefits of reminiscence therapy indementia, such as improvement in cognition and mood. Thereviewers encouraged its further development and evaluation.Further studies might focus on determining clearer treatmentprotocols, and exploring a potential interaction between sever-ity of depression and different treatment modalities (groupversus individual versus with caregiver).


A methodological limitation of many studies conducted inthis area is sampling strategy. Frequently, participants werenot selected according to a specific clinical pattern ofdepression, but based on their scores on various ratingscales. Thus, less is known about the efficacy of psychoso-cial interventions in treating clearly defined psychiatric syn-dromes. Many studies did not include follow-up assess-ments leaving the question of long term effects unanswered.Also, it is less clear whether and how these interventionsinfluence other outcomes such as functional dependence orcompliance with self-care (Hyer et al., 2005).

4.4 Pharmacological Interventions:Discussion and Recommendations

As noted above, a full set of recommendations can befound in the National Guidelines for Seniors’ MentalHealth: Assessment and Treatment of Depression(CCSMH 2006). Some basic recommendations are pro-vided below.

Recommendation: Depressive Symptoms:Pharmacological Interventions

First line treatment for residents who meet criteriafor major depression should include an antidepres-sant. [A]

Although the AGS/AAGP (2003) consensus statementendorses the above recommendation it also supports thebelief that for major depression, cognitive behaviouralpsychotherapy can also be effective. A 2003 literaturereview found 7 studies regarding antidepressants in LTChomes (Snowden et al., 2003). There were 2 placebo-controlled trials – one found nortriptyline to havegreater efficacy than the placebo and the other found nodifference between sertraline and the placebo (Katz et al.,1990; Magai et al., 2000).Ib Since that review, 4 clinicaltrials have been published including a comparison ofsertraline and venlafaxine, a placebo controlled trial ofparoxetine (negative result) and open label trials ofmitazapine (orally disintegrating tablets) and high dosesertraline (Burrows et al, 2002; Oslin et al, 2003; Rooseet al, 2003; Weintraub et al., 2003). The AGS/AAGP(2003) consensus statement also includes antidepres-sants as an option for treating minor depression (inaddition to non-pharmacological interventions)depending on factors such as severity, previous historyand resident/family preference.

Note: It is important to combine psychosocial inter-ventions with antidepressants whenever possible toobtain optimal outcomes.

The companion National Guidelines for Seniors’ MentalHealth: The Assessment and Treatment of Depression(CCSMH 2006) recommend the following with respectto antidepressants:

• Clinicians should start at half of the dose recommend-ed for younger adults and ensure that therapeuticdoses are reached as quickly as possible.

• Dosage should be increased every 5-7 days if tolerated,until there is clinical improvement or the average ther-apeutic dose has been reached. This will usually takeless than one month.

• Dosage should be increased beyond average therapeu-tic dose if there is no clinical improvement after 3-6weeks of treatment and there are no limiting sideeffects.

• In the absence of clinical response, an adequate antide-pressant trial usually consists of a 4 to 8 weeks trial atmaximum tolerated dose or maximum recommendeddose.

Visits to monitor antidepressant response shouldinclude, at a minimum, supportive psychosocial inter-ventions and monitoring for worsening of depressionand suicide risk. The companion National Guidelines forSeniors’ Mental Health: The Assessment and Treatment ofDepression (CCSMH, 2006) provides detailed recommen-dations regarding side effects, titration, augmentation andswitching antidepressants.


Appropriate first line antidepressants for LTC homeresidents include selective serotonin reuptakeinhibitors (e.g., citalopram and sertraline), venlafax-ine, mirtazapine, buproprion. [B]

Selection of an appropriate antidepressant medication forLTC home residents should be based on: a) previous histo-ry and experience of the resident; b) other medical comor-bidities; c) side effect profiles of the antidepressants; d)potential drug-drug interactions. The recommendationabove was endorsed by the AMDA guideline (2003).

Residents who start on serotonergic antidepressants (e.g.,SSRIs or venlafaxine) should be monitored for commonside effects such as nausea and diarrhea, as well as less com-mon ones, such as hyponatremia (leading to fatigue,malaise, delirium) or serotonin syndrome (with agitation,tachycardia, tremor, hyperreflexia). Venlafaxine can causeincreased blood pressure. There is an increased risk ofseizures with higher dosages of bupropion and weight gainis more common with mirtazapine.

There is some evidence supporting the use of moclobe-mide as a first line agent, although this antidepressant isnot commonly used in Canada. Mitazapine is availableas a rapidly dissolving wafer (Remeron-RD) which maybe useful for residents with swallowing problems.Escitalo-pram (the S-enantiomer of citalopram) hasrecently become available in Canada and may be a use-ful SSRI in seniors.


Tricyclic antidepressants (TCAs) may be used as secondline agents on occasion. Nortriptyline and desipraminemay be better tolerated than other tricyclics. Blood levelsof these agents may be helpful and should be usedbefore concluding that the drug is not effective (AMDA,2003). TCAs should not be used in residents with signif-icant cardiac conduction abnormalities. Cliniciansshould monitor for postural hypotension, cardiac symp-toms and anticholinergic side effects.


For residents with major depression with psychoticfeatures, a combination of antidepressant andantipsychotic medications is appropriate. [B]

The AGS/AAGP (2003) consensus statement endorsedthe above recommendation. Older adults with psychoticdepression who fail to respond to medication mayrespond to a course of ECT (Flint and Rifat, 1998).IIb


Residents with a first episode of major depressionresponding well to antidepressant treatment shouldcontinue on full dose treatment for at least 12months. Residents who have had at least one previ-ous episode of depression should continue withtreatment for at least two years. [A]

There is some debate regarding the minimum recom-mended period for continuation therapy with antide-pressants. The CPA/CANMAT guidelines (2001) suggest aminimum of 2 years in older persons. Alexopoulos andcolleagues’ (2001) Expert Consensus Guidelines onpharmacotherapy of depression endorse a minimum of12 months. For recurrent depression, we recommend aminimum of 2 years treatment and in some cases withmultiple serious recurrences lifelong treatment is recom-mended.


The treatment of depressed residents with a historyof bipolar mood disorder should include a moodstabilizer such as lithium carbonate, divalproex sodi-um or carbamazepine. [B]

Antidepressants can precipitate a manic or hypomanicepisode in residents with a history of Bipolar Mood

Disorder. This is less likely to occur if they are on a moodstabilizer. Detailed recommendations regarding the useof lithium carbonate can be found in the NationalGuidelines for Seniors’ Mental Health: The Assessment andTreatment of Depression (CCSMH 2006).


Residents with severe depression not responding tomedications should be considered for a trial of elec-troconvulsive therapy (ECT). (These residents willlikely require transfer to a psychiatric facility) [B]

A review of issues related to ECT in the LTC setting waswritten by Espinoza (2004).IIb The author reported thaton their ECT service almost 70% of patients admittedfrom LTC homes had a moderate or marked response toECT. The barriers to treatment were also highlightedincluding a lack of psychiatric consultants and limitedaccess to inpatient units where ECT is provided.


Psychostimulants (e.g., methylphenidate) may havea role in treating certain symptoms which are com-monly associated with depression (e.g., apathy,decreased energy). [C]

There is some literature suggesting benefits from psy-chostimulants for individuals with depression and apa-thy states following stroke and other neurological disor-ders (Grade et al., 1998).Ib

Depression frequently occurs in residents with coexistingdementia. Antidepressants are recommended in this popu-lation when the depression is persisting. Some good evi-dence for the efficacy of antidepressants comes from place-bo-controlled trials of Citalopram (Nyth et al., 1992)Ib andMoclobemide (Roth et al., 1996)Ib although not all partici-pants in these trials suffered from dementia.

A Cochrane Review (Bains et al., 2002) concluded thatavailable evidence offers only weak support for the con-tention that antidepressants are an effective treatmentfor older adults with depression and dementia. Theauthors also state: “it is not that antidepressants are nec-essarily ineffective but there is not much evidence tosupport their efficacy either” (Bains et al., 2002).However for persisting depression associated withdementia we believe that treatment should include anantidepressant.


5.1 Introduction

As in Part 4: Treatment of Depressive Symptoms and Disorders,we emphasize that we are aware that LTC homes differ intheir resources, and residents differ in the extent to whichfamily and friends are available and willing to be involvedin care. This section takes an aspirational approach to thetask of identifying psychological and social interventionsthat can contribute to the treatment of behavioural symp-toms of residents in LTC homes, recognizing that the reali-ty of what is available may differ.

Psychological and social interventions should generallybe utilized before initiating pharmacological treatment,however in urgent situations, or when symptoms aresevere it is appropriate to initiate pharmacological andnonpharmacological interventions together. Residentswith moderately severe symptoms may also benefit frommedication. It is worth noting that there is very limitedresearch evaluating the effectiveness of combined interven-tions. However, there is some evidence that individualizedtreatments that combine pharmacological and non-phar-macologicial interventions (e.g., providing structure, sched-uling events to adjust for individual residents’ needs,involving relatives in the treatment planning) can lead to asignificant reduction in agitation (Hincliffe et al., 1995;Rogers et al., 1999; Matthews et al., 1996). A randomizedcontrolled trial to test the hypothesis that individually tai-lored psychosocial, nursing and medical interventionswould reduce the frequency and severity of behaviouralsymptoms in nursing home residents with dementia foundimprovement in target behaviours in both groups. However,benefits were greater in the intervention group (Opie et al.,2002).

Brodaty and colleagues (2003a) provided a useful 7-tiered model of behavioural and psychological symp-toms of dementia (BPSD). They suggested that about50% of individuals with dementia would have mild ormoderate BPSD with approximately 10% having severeBPSD and less than 1% very severe symptoms. Cases ofextreme violence are fortunately rare. The model isintended to provide the basis for comprehensive plan-ning of service delivery.

5.2 Psychological and SocialInterventions: Discussion andRecommendations

Recommendation: Behavioural Symptoms:Psychological and Social Interventions

Social contact interventions should always be consid-ered, especially where the goal is to minimize sensorydeprivation and social isolation, provide distractionand physical contact, and induce relaxation. [C]

Social contact interventions are interventions that pur-posely expose the resident to elements in the social envi-ronment, including family, friends, staff, and pets. Thegoal is to promote interaction and/or stimulation.Interventions may be in vivo, virtual, active, passive,video, audio, personally relevant or generic. There issome research support for one-to-one interactions, simu-lated interactions (e.g., family generated videotapes andaudiotapes and generic videotapes) and pet therapy (e.g.,real and artificial).

One-to-one interactions may be effective in preventingand managing agitated behaviours (McGonigal-Kenney& Schutte, 2004).III One-to-one interactions may includeactivities such as talking, singing, hands-on activities,exercising, touch, food, and theme bags (McGonigal-Kenney & Schutte, 2004).III Providing direct stimulationfor approximately 30 minutes appears to have some ben-eficial effects (Cohen-Mansfield & Werner, 1997).III

Additionally, it has been suggested that one-to-one inter-actions may be more effective for those who are verballyagitated, and less cognitively and functionally impaired(Cohen-Mansfield & Werner, 1997).III

Simulated interaction interventions involve using videoand/or audio equipment to simulate interactions withsignificant others. Family generated videos characterizedby expressions of love and respect with a focus on pastevents appear to produce more favorable effects com-pared to generic videos aimed at inducing relaxation andreminiscence (Hall & Hare, 1997; Werner et al., 2000).Cognitively impaired females with verbally agitatedbehaviours tend to benefit most from watching familygenerated videos (Werner et al., 2000).III More structuredguidelines on how to prepare family videos are needed.Werner and colleagues (2000) noted that the relativesinvolved in preparation of family videos felt over-whelmed at times. Further research can identify the rea-sons behind these reactions, which, in turn, can help inthe preparation of videos.

There is anecdotal evidence supporting the use of com-panion animals to enhance well being in residents withdementia. For example, Churchill and colleagues(1999)III concluded that the presence of a dog enhancedsocialization (as evidenced by increased verbalization,smiling and looking), and decreased the amount of agi-tated behaviour in residents with dementia. Libin andCohen-Mansfield (2004)IIa reported that interacting withboth a robotic pet and a plush toy cat can decrease agita-tion, and increase pleasure and interest in elderly per-sons with dementia. Further studies regarding potentialbenefits of robotherapy (i.e., artificial companions) areneeded. It is difficult to make generalizations based on asingle pilot study in this area.

Part 5: Treatment of Behavioural Symptoms


It remains unclear what are the active ingredients ofsocial contact interventions. An important issue to con-sider is whether and how much these interventions satis-fy social needs of LTC residents as opposed to their needsfor stimulation or distraction.


Sensory/relaxation interventions (e.g., music, snoeze-len, aromatherapy, bright light) should be consideredwhere the goal is to reduce behavioural symptoms,stimulate the senses and enhance relaxation. [B/D]

Sensory/Relaxation interventions encompass a widerange of interventions with varying levels of evidence.Interventions and their accompanying strengths of rec-ommendations are as follows:

Music [B]Different forms of music have been proposed as inter-ventions for agitated behaviours (e.g., active versus recep-tive; individualized versus standard classical relaxationmusic; music during bathing or meals versus individualrelaxation sessions). In a recent review of randomizedcontrolled trials, the authors concluded that there was nosubstantial evidence to either support or discourage theuse of music therapy for treatment of aggression, agita-tion, and wandering in older people with dementia(Vink et al., 2003)Ib. However, other reviewers who didnot limit themselves to randomized trials commentedthat individualized music could have beneficial, short-term effects on agitation (Cohen-Mansfield, 2001;Snowden et al., 2003).IIa

It has been suggested that each music session should lastapproximately 30 minutes and occur prior to the resi-dent’s usual peak level of agitation (e.g., Gerdner,2000).IIa Additionally, it is important to monitor all resi-dents closely, particularly those with comorbid psycho-logical or medical problems and impaired hearing. Morerefined studies regarding the effects of music therapy forpeople with dementia are needed (Vink et al., 2003). Inparticular, studies are needed on the medium and longterm effects of this therapy.

Snoezelen [B]Snoezelen, an intervention that combines soft music,aromatherapy, textured objects, favorite food, and col-ored lighting in a designated space (usually a room with-in the facility), is intended to promote a failure-free,relaxing and enabling physical environment (Chitsey etal., 2002). In a review of randomized controlled trials, itwas noted that snoezelen could have positive immediateeffects on apathy, restless and repetitive behaviours(Chung & Lai, 2002).Ia However, the effects seem to beconfined to the snoezelen sessions or the period imme-diately after the sessions.

Some short-term beneficial effects of snoezelen on moodand agitation have been noted. However, there is consid-erable variation between individuals in their reactions tosnoezelen (Baillon et al., 2004).Ib A number of researchquestions regarding snoezelen need to be addressed. It isstill unclear how frequent and how long snoezelen ses-sions should be, at what stage of dementia residents canbenefit most, and whether there are long term effects. Animportant question to consider is whether snoezelenpromotes a therapeutic relationship between residentsand staff (Chung & Lai, 2002).

Aromatherapy [C]Aromatherapy, either alone or in combination withother sensory stimulating activities, has been proposedas another sensory intervention. It was observed that atopical application of Melissa officinalis to the residents’face and both arms twice a day led to a reduction in agi-tation and increase in overall well-being as indicated bya decrease in social withdrawal and increase in timeengaged in constructive activities (Ballard et al., 2002).IIa

Lavender oil administered in an aroma stream produceda modest reduction in agitated behaviours in residentswith severe dementia (Brooker et al., 1997IV; Holmes etal., 2002IIa).

In studies exploring the efficacy of aromatherapy, aro-matherapy was used in conjunction with prescribed psy-chotropic medications. Examining whether aromathera-py alone can be a viable treatment alternative would bea next step. It is interesting to note that people withdementia with Lewy bodies (DLB) showed no evidenceof improvement while being treated with aroma streamsof lavender oil (Holmes et al., 2002). Larger studies, withdifferent forms of dementia and with different adminis-tration techniques are needed.

Bright Light Therapy [D]Degenerative changes in the suprachiasmatic nuclei(SCN) of the hypothalamus appear to be associated withcircadian disturbances in the elderly, particularly in thosewith dementia (Forbes et al., 2004). A number of studiesexplored whether these changes may be reversed by stim-ulation of the SCN with light. In a meta-analytic reviewof randomized trials, it was concluded that there wasinsufficient evidence to support the efficacy of brightlight therapy (BLT) in managing sleep, agitation, cogni-tion and mood in dementia, and that further studieswere warranted (Forbes et al., 2004).Ia

Similarly, in her review of both observational and ran-domized studies, Cohen-Mansfield (2001) noted thatthe results were inconclusive as some studies reported noeffects; some reported significant decreases whereassome reported trends. Given the mixed results, the het-erogeneity of participants within and across the studies,and a lack of consensus regarding the timing of BLT, fur-ther studies regarding the efficacy of BLT are needed. In


many studies, participants were not homogenous interms of their diagnoses and severity of dementia. AsForbes and colleagues (2004) indicated, responses to BLTmay depend on the area of the brain that has been affect-ed by pathological changes. Additionally, Ancoli-Israeland colleagues (2003) suggested that persons with mildto moderate Alzheimer’s disease may benefit from BLTmore than those with severe Alzheimer’s disease. Furtherstudies that address the intensity and frequency of BLTare needed, as well as studies that explore the timing andlength of BLT interventions.

In the meantime, BLT should be administered cautiouslyin older adults with dementia, particularly when agita-tion increases or delusions develop during BLT(Schindler et al., 2002).IV It has been suggested thatblurred vision (e.g., due to cataracts) should be ruled outbecause it could contribute to misjudgments whileadministering BLT (Schindler et al., 2002).IV

BLT can be administered using the following protocols:• “Brite-Lite” boxes (2,500 to 10,000 lux) placed one

meter from the person. Light can be administered forapproximately 2 hours in the morning (e.g., Ancoli-Israel et al., 2003; Lovell et al., 1995).

• Increase the light intensity used during meal times toenhance visual stimulation (Koss & Gilmore, 1998).

White Noise [D]Exposure to any low intensity, slow, continuous, rhyth-mic, monotonous sound (i.e., white noise) has been pro-posed as an auditory intervention for agitated behav-iours. Evidence for its efficacy is still inadequate. Whitenoise might have potential to reduce verbal aggression(Burgio et al., 1996).III

Massage and Touch Interventions [D]Studies exploring the effects of massage and touch inter-ventions produced mixed findings. A ten-minute thera-peutic touch administered during a three-day treatmentperiod led to a significant decrease in vocalization andpacing with a sustained treatment effect over 1 to 1.5days (Woods & Dimond, 2002).IIb This interventioninvolved directing attention inward on the part of theprovider, and performing gentle movements as describedin the “Ten-minute therapeutic touch protocol”(Quinn,1984). However, Snyder and colleagues (1995)IIb report-ed no consistent effects using a similar ten-minute thera-peutic touch protocol and a five-minute hand massageprotocol. On the other hand, Kim and Bushmann(1999)III reported a significant decrease in agitation dur-ing a five-minute hand massage treatment. A combina-tion of music and massage therapy did not seem to berelated to a decrease in agitation (Snyder & Olsen,1996).III


Structured recreational activities should be consid-ered where the goal is to engage the resident. [C]

Structured activities with individuals or groups mayinvolve manipulation, exercise, outdoor walks, multi-sensory stimulation, pet therapy, and one-to-one super-vised gardening. Engaging residents during idle timescan reduce agitation (Aronstein et al., 1996).IV Outdoorwalks can be designed to meet physical and social needsand reduce wandering. Physical exercise appears to berelated to a reduction in repetitive, and disruptive activi-ties (Beck et al., 1992).IV Structured activities include:

Recreational Activities [C]• Sorting (e.g., puzzles, cards, clothing).• Sewing (e.g., fabric squares, lacing tiles).• Sound and music programs.• Manipulative activities (e.g., bead mazes, flexible

cubes).• Cooking program, herb garden program, horticultural

activities (Cohen-Mansfield, 2005).• Montessori-based activities (Schneider & Camp, 2002)• Activity aprons (e.g., aprons that have buttons, zippers

and other articles sewn on) (Cohen-Mansfield, 2005).• Outdoor gardening with one-to-one supervision

(Cohen-Mansfield & Werner, 1998; McGonigal-Kenney & Schutte, 2004).III

Walking Activities [C]• Walking programs, outdoor walks, and group walks

through public areas of the LTC facility (Cohen-Mansfield, 2005).

• Residents in walking groups could walk significantlylonger compared to baseline performance (Tappen etal., 2000).

Physical Activities [C]• Physical group activity programs designed to improve

strength and flexibility. • Both high and low level mobility residents can benefit

from mobility programs comprising of warmup/stretching, walking, lower body strengthening,upper body strengthening, balance, and cooldown/stretching (Lazowski et al., 1999).Ib

• See McGonigal-Kenney and Schutte’s (2004) guide-lines for specific protocols regarding two physical exer-cise programs.

Recreational interventions and other structured activityprograms may be helpful in the management of agitatedbehaviours in residents with Alzheimer’s disease (AD)and other dementias (Aronstein et al., 1996).IV Agitatedbehaviours decreased when residents were involved inactivities and not restrained (Cohen-Mansfield & Werner,


1998). A physical training program improves mobility,flexibility and static balance in residents with dementiawho are also at risk for falls (Toulotte et al., 2003).Ib

Holmberg (1997)II found a 30% reduction in aggressiveevents in LTC homes on days when residents were takenfor group walks compared to days without walks.Structured activities are an important component of psy-chosocial rehabilitation, which, as related to seniors’mental health, promotes optimal performance in areasof cognition, interpersonal skills, self-care, leisure, andutilization of community resources.


Individualized behaviour therapy should be consid-ered where the goal is to manage behaviour symp-toms (e.g., contextually inappropriate, disturbing,disruptive or potentially harmful behaviours). [C]

Behaviour therapy, grounded in a belief that all behaviourhas meaning, focuses on intra-individual (i.e., biopsychoso-cial) and extra-individual factors (e.g., contextual, social) inassessment and management. This approach (whichemphasizes least restrictive and least intrusive interventionsand individualized care planning) has been found useful inreducing both incidences of resident injuries and stressamong staff (Gibson & Bol, 1996).

The selection of specific behavioural interventions shouldbe based on a solid behaviour analysis (ABC). Moreover,it is important to note that the process of behaviouranalysis (i.e., describing the relationships amongantecedents, behaviours and consequences) can in itselfhave beneficial effects, often through the changes in staffbehaviour that follow from increased understanding(Rewilak, 2001).

Support regarding the efficacy of behavioural interven-tions comes mainly from case-reports and observationalstudies (Cohen-Mansfield, 2001; Landreville et al., 1998;McGonigal-Kenney & Schutte, 2004; Snowden et al.,2003).III These studies targeted a variety of problematicbehaviours (such as noisemaking, wandering, ADL,bathing, inappropriate toileting, sexual behaviour, verbaland physical aggression). Behavioural interventions inmany studies were individualized and led to a reductionin targeted, problematic behaviours. The following inter-ventions were supported:

Differential reinforcement • Reinforce either quiet behaviour or behaviour that is

incompatible with the inappropriate behaviour.• Compliments, soothing speech, praise, and food may

serve as rewards.• The principle of successive approximation toward the

desired behaviour can be employed (i.e., reinforcesmall steps towards the desired behaviour).

Differential reinforcement appears to be an effectiveintervention for both aggressive and verbally agitatedbehaviours (Landreville et al., 1998).IV

Stimulus control • Establish an association between a stimulus and a par-

ticular behaviour (e.g., a large stop sign with stoppingand walking away).

• Verbal and/or physical prompts can be used to helpresidents attend to various stimuli (e.g., Hussian,1988).III

• Making antecedents more salient or making associa-tions between various consequences and antecedentsmore salient seems to be effective with residentsexhibiting physically nonaggressive behaviours such aswandering (Cohen-Mansfield, 2001; Landreville etal.,1998).IV

Several case and small-sample studies reported thatextinction (i.e., attention given in the absence of undesir-able behaviours) might not be an effective strategy in itself(Bourgeois & Vézina, 1998; Heard & Watson, 1999;Hussian, 1983).IV It has been suggested that instruction inpositive self-statements, in addition to extinction, mightproduce desirable effects (Cohen-Mansfield, 2001).IV

Two recent randomized controlled trials produced someequivocal results regarding the effectiveness of behav-ioural management techniques (Gormley et al., 2001;Teri et al., 2000). These studies evaluated the programswithin which family caregivers used behavioural tech-niques to manage aggressive and agitated behaviours inolder adults with dementia. Gormley and colleagues(2001)Ib reported a trend toward a reduction in aggres-sion for participants in a behaviour management train-ing group (BMT). BMT training in this study consisted ofavoidance or modification of precipitating and main-taining factors, use of appropriate communication (e.g.,calm approach, simple one-step commands), validation(e.g., acceptance of false statements) and distraction. Teriand colleagues (2000)Ib demonstrated a comparablemodest reduction in agitation in older adults with ADreceiving haloperdol, trazodone, BMT, and placebo. BMTconsisted of structured sessions that provided informa-tion about AD to care providers, strategies for decreasingagitated behaviours, in-session and out-of-sessionassignments, and watching a video training program.However, the treatment protocols were not individual-ized and did not target specific needs and problems ofthe participants.

Behavioural programs typically are multimodal. Forexample, DeYoung and colleagues (2002) evaluated theimpact of a behaviour management program for careproviders of persons with dementia on aggression, agita-tion, and disruptive behaviour. In a 28-hour educationprogram, staff learned how to utilize behavioural strate-gies and strategies for making the social and physical


environment more responsive to residents’ needs. Theywere also taught the importance of knowing the residentas a unique individual and of consulting with other staffto help with care. Participation in the program was asso-ciated with a reduction in aggression, agitation, andother disruptive behaviours. The interventions that wereeffective in reducing the behaviours included verbal dis-traction, time out, activity diversion, getting to know theperson well, and managing the social and physical envi-ronment.

Ledoux and colleagues (2000) created an aggressive anddisruptive behaviour management program which inte-grated clinical, health, and workplace safety considera-tions. The authors concluded that an individualizeddiversionary strategy, utilizing historical and proceduralmemories, combined with modifications to the physicaland social environment, was effective in reducing aggres-sive and disruptive behaviour during basic care. A diver-sion was created by drawing attention to something thatwas significant to the resident to prevent him/her fromfocusing on the care. A second diversion strategyinvolved triggering an automatic gesture to prevent theresident from becoming agitated (e.g., asking the resi-dent to wash his/her hands while the nurse washes thegenital region).

There is a need for a greater number of randomized tri-als that would address the efficacy of behavioural inter-ventions. Studies addressing what benefits specific BMTcomponents add above and beyond the benefits that reg-ular contacts, support and encouragement provide areneeded. Additionally, studies that address longer follow-up periods are warranted.

5.3 Pharmacological Interventions:Discussion and Recommendations

Before pharmacological treatment is considered it isimportant to attempt to use nonpharmacological inter-ventions. However, in some urgent situations it may benecessary to introduce pharmacological and nonphar-macological interventions simultaneously. Two recentcomprehensive reviews provide details of the evidenceregarding the efficacy of pharmacological treatments ofbehavioural symptoms associated with the dementias(Sink et al., 2005; Weintraub & Katz, 2005).

Recommendation: Behavioural Symptoms:Pharmacological Interventions

Carefully weigh the potential benefits of pharmacolog-ical intervention versus the potential for harm. [A]

Several factors make LTC homes a unique setting for pre-scribing medication. These include the extreme frailty ofthe population, the complexity of the social institution,limited physician availability, care team members impor-

tant contributions to treatment decisions, the potentialrole of the pharmacist, limited staffing levels, and staffeducation. Individuals over the age of 65 are particularlyvulnerable to drug-related problems because of co-mor-bidities, physiological changes of ageing, and the largenumber of medications they are prescribed. Thus, thereare several general principles that should be consideredin the development of any care plan that includes med-ication. These are discussed in Appendix B.


Appropriate first line pharmacological treatment ofresidents with severe behavioural symptoms withpsychotic features includes atypical antipsychotics.[B] Atypical antipsychotics should only be used ifthere is marked risk, disability or suffering associatedwith the symptoms. [C]

It is important to be aware that certain behaviours areunlikely to respond to medications (e.g. wandering, exit-seeking behaviour, and excessive noisiness).

The best evidence from placebo-controlled trials in LTChomes would support the use of atypical antipsychotics(Brodaty et al., 2003b; De Deyn et al., 2004, 1999; Katz etal., 1999; Street et al., 2000).Ib The AGS/AAGP (2003)consensus statement endorsed the above recommenda-tion. The studies above compared olanzapine or risperi-done to placebo. A recent Cochrane review of the effec-tiveness of atypical antipsychotics for the treatment ofaggression and psychosis in Alzheimer’s disease exam-ined 16 placebo controlled trials and included 9 in themeta-analysis (Ballard & Waite, 2006). The review con-cluded that risperidone and olanzapine are useful inreducing aggression, and risperidone reduces psychosis.Despite the modest efficacy, the significant increase inadverse events suggested that neither risperidone norolanzapine should be used routinely to treat residentswith aggression or psychosis unless there is marked riskor severe distress. Three other recent reviews provide use-ful perspectives (Carson et al., 2006; Lee et al., 2004; vanIersel et al., 2005).

Clinicians should carefully evaluate risks versus benefitsin each resident and obtain informed consent. There issome evidence from placebo-controlled trials of anincreased mortality rate among subjects receiving atypi-cal antipsychotics versus placebos (1.5-1.7 fold increasein mortality rate; Schneider et al., 2005; U.S. Food andDrug Administration, 2005). There is also evidence ofan increased risk of cerebrovascular events. Possible sideeffects also include extrapyramidal symptoms, gait dis-turbance, sedation, widening of the QTc interval, anti-cholinergic effects (including delirium), and metabolicdisturbances such as an increased risk of developingdiabetes.


In view of the above warnings many experts in thefield believe that the use of antipsychotics in individ-uals with dementia should be reserved for residentswith severe agitation or psychosis, where severity isevaluated on the basis of the degree of danger, suffer-ing or excess disability (Weintraub & Katz, 2005).Clinicians should aim for the lowest possible effectivedosage.


Appropriate first line pharmacological treatment ofresidents with severe behavioural symptoms with-out psychotic features can include: a) atypicalantipsychotics; b) antidepressants such as tra-zodone or selective serotonin reuptake inhibitors(e.g., citalopram or sertraline). Antipsychotics [B];Antidepressants [C]

There is limited evidence for the effectiveness of antide-pressants in the treatment of behavioural symptoms. Inone placebo-controlled randomized controlled trial(RCT) citalopram was significantly superior to placeboand appeared to outperform perphenazine (Pollock etal., 2002).Ib However, a recent review of placebo con-trolled studies noted that 4 other trials of serotonergicantidepressants reported negative results (Sink et al.,2005).Ib A study comparing trazodone to haloperidolreported equal improvement in agitation (Sultzer et al.,1997).Ib


Pharmacological treatment of residents with severebehavioural symptoms can also include: a) anticon-vulsants such as carbamazepine; b) short or interme-diate acting benzodiazepines. Carbamazepine [B];Benzodiazepines [C]

There is some evidence from a placebo-controlled RCTthat carbamazepine improves agitation (Tariot et al.,1998)Ib although Olin and colleagues (2001) found limit-ed benefit in their study. Potential adverse effects of carba-mazepine include hepatic toxicity and blood dyscrasias.Placebo-controlled RCTs of divalproex sodium found nobenefit (Porsteinsson et al., 2001; Tariot et al., 2005).Ib

Pharmacoepidemiological studies suggest that benzodi-azepines are frequently used in LTC homes in manycountries for anxiety, insomnia and behavioural symp-toms (Conn et al., 1999). As there is limited evidence forthe efficacy of benzodiazepines for agitation in this pop-ulation, they should not be used as first line agents. Inmost cases, their use should be limited to brief periods(e.g., 2-3 weeks). It may be appropriate to use shorter act-ing benzodiazepines on an as needed (p.r.n.) basis. Two

RCTs suggested that benzodiazepines were as effective aslow dose haloperidol (Christensen & Benfield, 1998;Coccaro et al., 1990). Benzodiazepines can occasionallycause paradoxical disinhibition. They may cause exces-sive sedation, gait disturbance, falls and worsen cogni-tion. Use of long-acting benzodiazepines (e.g.,diazepam) should be avoided in this population.

Combination pharmacological therapy for residentswith severe behavioural symptoms may be necessary ifmonotherapy of sufficient dose and duration is unsuc-cessful.

In emergency situations when the resident or others arein danger of physical harm pharmacological optionsinclude: haloperidol IM, loxapine IM or olanzapine IM.Oral rapidly dissolving tablets (e.g., olanzapine[Zyprexa Zydis] or risperidone [Risperidal M-tab]) mayalso be useful when the resident is somewhat coopera-tive. Benzodiazepines (e.g., lorazepam) may also beuseful. Meehan and colleagues (2002)Ib found that IMolanzapine and IM lorazepam were effective in treatingagitation associated with dementia (after 2 hours). After24 hours, subjects receiving olanzapine maintainedsuperiority over placebo, whereas those who receivedlorazepam did not.

Note: It is rarely necessary to use IM medications in LTChomes. If necessary, it is important to use much lowerdosages in the elderly (e.g., dosages of haloperidolshould start at 0.5 – 1.0 mg. IM). The risk of extrapyra-midal side effects (e.g., acute dystonia) is greater withconventional antipsychotics (e.g., haloperidol).


Appropriate pharmacological treatment of residentswith severe sexual disinhibition can include: a) hor-mone therapy (e.g., medroxyprogesterone, cypro-terone, leuprolide); b) selective serotonin reuptakeinhibitors; or c) atypical antipsychotics. [D]

There is very limited evidence, primarily case reports, insupport of pharmacological treatment for inappropriatesexual behaviour, (Cooper 1987; Levitsky & Owens,1999).IV Hormone therapies are generally used with menin severe situations when other interventions have failed.Common side effects include weight gain, breast pain,depression and oedema. There may be an increased riskof thromboembolism. Black and colleagues (2005)recently carried out a review of these behaviours andavailable treatments.



Appropriate pharmacological treatment of behav-ioural symptoms associated with frontotemporaldementia can include trazodone or selective sero-tonin reuptake inhibitors. [B]

This recommendation is primarily based on two smallRCTs (Lebert et al., 2004; Moretti et al., 2003).Ib Lebertand colleagues (2004) compared trazodone to placeboand reported some benefits particularly with irritability,agitation, depressive symptoms and eating disorders.Moretti and colleagues (2003) reported some behaviour-al benefits with paroxetine in a 14-month randomized,controlled open label study.


Appropriate pharmacological treatment of residentswith behavioural symptoms or psychosis associatedwith Parkinson’s disease or dementia with Lewybodies includes: a) cholinesterase inhibitors; or as alast resort b) an atypical antipsychotic with less riskof exacerbating extrapyramidal symptoms, (e.g.,quetiapine). Cholinesterase inhibitors [B];Quetiapine [C]

One placebo-controlled RCT of rivastigmine (acholinesterase inhibitor) in Dementia with Lewy Bodies(DLB) found benefits in behavioural symptoms includ-ing hallucinations (McKeith et al., 2000).Ib

Antipsychotics should generally be avoided in residentswith DLB as they may develop severe adverse effects.Evidence regarding the use of atypical antipsychotics inDLB is limited to case series. If an antipsychotic isabsolutely necessary in residents with Parkinson’s dis-ease, quetiapine may be less likely than other atypicals

to exacerbate the motor symptoms (Friedman & Factor,2000). If there is no response to a cholinesteraseinhibitor or quetiapine, there is some evidence to sup-port the use of clozapine for psychosis associated withParkinson’s disease, with appropriate monitoring foragranulocytosis (Morgante et al., 2004).

Note: There is evidence that cholinesterase inhibitors(e.g., donepezil, galantamine and rivastigmine) andmemantine may delay the emergence of behaviouralsymptoms in Alzheimer’s Disease and other dementias.A recent meta-analysis of cholinesterase inhibitors inolder adults with Alzheimer’s disease suggested small butstatistically significant improvement in studies using theNPI (Neuropsychiatric Inventory) as an outcome measureand a trend towards benefit in studies using the ADAS-noncog (Trinh et al., 2003).Ia

There is urgent need for more studies of residents withbehavioural symptoms. We need to establish better pre-dictors of response to particular groups of medication.Large scale trials comparing the effectiveness of thesemedications would also be invaluable.


Pharmacological treatments for behavioural symptoms orpsychosis associated with dementia should be evaluatedfor tapering or discontinuation on a regular basis (e.g.,every 3-6 months). Ongoing monitoring for adverseeffects should be under taken. [A]

The AGS/AAGP (2003) consensus statement supports theabove recommendation with a review being carried out atleast every 6 months. At least 3 RCTs have demonstratedthat it is possible to successfully withdraw antipsychoticmedication in the majority of residents following a periodof stability (Ballard et al. 2004; Cohen-Mansfield et al.1999; van Reekum et al. 2002).Ib


6.1 Introduction

The recommendations in this section relate to a) organi-zational issues and b) system issues. Organizationalissues focuses on internal policy and procedures, such ashuman resource practices, whereas system issues focuson community context and partnerships.

6.2 Organizational Issues: Discussion andRecommendations

Recommendation: Organizational Issues

LTC homes should develop the physical and socialenvironment as a therapeutic milieu through theintentional use of design principles. [D]

Given the importance of the physical and social environ-ment in LTC homes for meeting the goals of care, it is rec-ommended that the setting be developed as a therapeu-tic milieu through the intentional use of guidelines andprinciples for designing the physical environment andadjusting the social environment.

Factors in the social environment (e.g., philosophy ofcare, how care is provided, relational and social opportu-nities, activity, staff communication) and in the physicalenvironment (e.g., space, noise, security features, layout,legibility) form the milieu. A therapeutic milieu can bedesigned to promote the mental health of all residents(e.g., decrease noise by eliminating overhead paging andcall bells) or to address individual issues (e.g., peer sup-port for a depressed resident, consideration of roommatecompatibility) (Verma et al., 1998).

Many of the social characteristics of the milieu are men-tioned in the preceding sections. It is beyond the scope ofthese Guidelines to review the literature on designingthe physical environment in detail. However the impor-tance of this literature to the design of an effective ther-apeutic milieu is acknowledged.

Important aspects of this literature address such issues asreducing agitation through management of unit size anddesign (Houde, 1996; Williams-Burgess et al., 1996) andcontrol of environmental stressors (Kovach & Meyer,1997). The Eden Model is a well-known example of asystemic approach to physical design that relies on theprinciples and values that should underlie resident care(www.edenalt.com). In a study that examined the impactof the Eden Model on quality of life and quality of worklife in five LTC homes, the number of aggressive inci-dents by residents decreased by 60%, staff moraleincreased and staff injury and absenteeism decreased(Ransom, 2000).

The Alzheimer Society of Canada has developed guidelinesfor physical design that are applicable to LTC homes(www.alzheimer.ca). Supportive physical design pro-vides safe shelter, accommodates individuality, enablesphysical function, and fosters social interaction andmeaningful activities.

Similarly, the CCSMH developed a set of guidelines,titled Supportive Physical Design Principles for Long-TermCare Settings. The Guidelines address features of themilieu (physical and social environment) that supportand enhance resident well being. Detailed recommenda-tions can be found at http://www.ccsmh.ca/en/designPrinciples.cfm, and include the following: • Maximize safety and security• Maximize awareness and orientation• Support functional abilities through application of

principles of psychosocial rehabilitation• Facilitate social contact and interaction• Provide for privacy• Provide opportunities for personal control• Regulate the quantity and quality of stimulation • Promote continuity of the self


LTC homes should have a written protocol in place relatedto staffing needs specific to the care of older residents withmood and/or behavioural symptoms. [C]

Staffing levels and mix related to case mix index ofteninfluence the ability to provide appropriate levels of care.While there is limited evidence regarding staff needs inLTC homes, judgement of appropriate staffing patternsin nursing is an important factor in the provision of safeand competent care. Staffing decisions must take intoaccount resident acuity, complexity level, and the avail-ability of expert resources.

The literature suggests that the ratio of registered nursesto residents, along with other defined factors such asexperience of staff, significantly influences clinical out-comes in a positive way (Anderson et al., 2003). A studyfunded by the Centers for Medicare and MedicaidServices (2001) found that higher staffing levels for long-stay residents were related to fewer pressure ulcers,reduced skin trauma, and less weight loss. Theresearchers found that for every unit increase in staffingthere was a positive improvement in resident outcomes.There was also a threshold for minimum staffing, whichwas 2.8 hours per resident per day (hprd) for nursingassistants/personal support workers, and 1.3 hprd for alllicensed staff. Schnelle (2004) confirmed this threshold.Nursing homes in the upper 10th percentile on staffing(>4.1 hprd) performed significantly better on 13 of 16

Part 6: Organizational and System Issues


care processes (such as assisting with eating or toileting).In Canada, the Canadian Nursing Association has draft-ed a document, Health Human Resources KnowledgeSeries on evaluation of staff mix (http://www.cna-a i i c . c a / C N A / d o c u m e n t s / p d f / p u b l i c a t i o n s /Final_Staf_Mix_Literature_Review_e.pdf).

Research is required to understand the specific staffingratio and mix of staff required to care for older personswith mood and/or behavioural symptoms. Moreresearch is needed to define the roles of various types ofpractitioners (e.g., registered nurses, registered practicalnurses, healthcare aides, personal support workers) inthe care of residents with mood and behavioural symp-toms.


LTC homes should have an education and trainingprogram for staff related to the needs of residentswith depression and/or behavioural concerns.Ideally dedicated internal staff would be available toprovide leadership in this area, including the devel-opment and delivery of best practices. [C]

Poor education and training can compromise resident careand safety (Anderson et al., 2005). Care providers requireeducation and training in the detection and management ofdepressive and behavioural symptoms (Boustani et al.,2005).III Expert opinion suggests that education is necessary,but is often not sufficient to improve practice. Supportingcare providers to make the transition from ‘knowing’ to‘doing’ is complex. There is no single process of knowledgeutilization (KU) that describes how all staff use knowledgein different practice settings.

Anderson and colleagues (2005) found that effective nurs-ing home care involves sufficient cognitive diversity amongcare providers, that is, the system has a variety of people indiverse roles who make new information available. Severalstrategies supporting the education and training needs ofcare providers caring for clients with depression and/orbehavioural concerns have been found effective. One is tocreate an internal clinical resource team, which includesreallocating internal resources, and another is to hire anadvanced practice nurse or nurse practitioner for the facility(Kane et al., 2002; Ryden et al., 2000). These two strategiesaim to: provide support to front line care providers who areproviding services and support to older persons; engage inidentifying and facilitating the delivery of learning anddevelopment of strategies in the facility aligned with bestpractice and the realities of the LTC facility; assist in identi-fying improvements in policy and practice related to identi-fied issues in the LTC home; be an internal resource thatworks with and connects effectively in collaborative rela-tionships with external resources; and reports directly tosenior administration.

Residents with Advanced Practice Nurses (APN) as partof their care have been shown to experience significantlygreater improvement or fewer declines in incontinence,pressure ulcers and aggressive behaviour (Ryden et al.,2000). As well, significantly less deterioration in affectwas noted. Residents in nursing homes affiliated withAPNs had family members that expressed greater satis-faction with the medical care their relatives received(Kane et al., 2002).

An Ontario program called PIECES is an example of aninternal resource within a nursing home, whichimproves the behavioural care of residents (http://www.piecescanada.com/pc-on.html). It is a comprehensiveprovincial training strategy to enhance the ability ofhealth professionals to meet the care requirements ofindividuals with complex physical and cognitive/mentalhealth needs and with associated behavioural issues.PIECES provides a framework for understanding and sys-tematically assessing the meaning behind the observedbehaviour. Other Canadian educational resourcesinclude the book Practical Psychiatry in the Long Term CareFacility: a Handbook for Staff (Conn et al., 2001) and aCCSMH educational inventory “Educational Materials forFront Line Workers” (www. ccsmh.ca).

An additional strategy to improve training and educationof staff is to collaborate with academic programs (includ-ing academic appointments for facility staff as appropri-ate) as a means of promoting knowledge transfer andtranslation. Further, administrators, directors of care, andcharge nurses within LTC homes are required to provideleadership to enhance residents’ care and to support theutilization of new evidence into practice (Anderson etal., 2005). Very little is known about how to improve themanagement and supervision of nursing home care, andthus further research is required.

There is no single process of KU that describes how allcare providers use knowledge in different practice set-tings. It would be premature to apply the findings of KUstudies conducted in acute care settings with profession-al health care practitioners to LTC homes and withunregulated care providers such as personal supportworkers. Therefore, more specific KU research is requiredin LTC homes.


LTC homes should have a written protocol in placerelated to the administration of medication by para-professional staff. [D]

Practices vary across the country in regards to the adminis-tration of medications within LTC homes by nonregulatedand regulated nursing staff. However, we believe that LTChomes should have a written protocol to guide practice on


this issue. Administration of medications must be consis-tent with professional practice legislation, health care legis-lation, and educational standards. As a component of thisprotocol, it should be specified that any staff memberadministering medications must monitor and documentthe resident’s response to drug therapy. Continuing educa-tion for staff related to the administration and monitoringof drug therapy specific to the needs of older residents isessential.


LTC homes should have a written policy in placeregarding the use of restraints. [D]

The issue of restraints is important to this discussionof the assessment and management of behaviouralsymptoms in LTC homes, since it needs to be empha-sized that restraint is not a therapeutic response tobehavioural symptoms. Rather, the use of physicalrestraints should be understood as a short-term inter-vention implemented only under very restricted cir-cumstances.

The reader is referred to the companion National Guidelinefor Seniors’ Mental Health: The Assessment and Treatment ofDelirum (CCSMH 2006) for a detailed discussion onrestraints, including specific recommendations.

6.3 Systems Issues: Discussion andRecommendations

Recommendation: System Issues

LTC homes should obtain mental health servicesfrom local practitioners or multidisciplinary teams,with interest and expertise in geriatric mental healthissues. [D]

We support expert opinion and previous guidelines thathave contended that LTC homes need access to mentalhealth experts. In some regions, psychogeriatric outreachteams may be available to provide assessment, treatmentand staff education. Another option is to contract withindividual practitioners. Regional acute care specializedinpatient services should be available for residents whosebehaviours cannot be managed by the LTC facility. SomeLTC homes may have special units where enhanced carecan be provided.

Unfortunately many regions across the country have verylimited access to such services. New technologies may allowfor the provision of consultation through interactive video-conferencing (telehealth). In a few rural regions in Canada,consultation via telehealth is being used to complementlocal geriatric mental health services.


Administrators and managers within LTC homesshould be prepared to advocate with local, provin-cial, and national policy makers and funding agen-cies to promote the health and well being of olderresidents. [D]

In order to advocate on behalf of their residents, admin-istrators and managers within the facility are responsiblefor being aware of current epidemiological trends andrelated health care needs of an aging population, withspecific attention to the incidence of depression andbehavioural symptoms in LTC residents. Canadianhealth documents, for example, Building on Values: TheFuture of Health Care in Canada Report (Commission onthe Future of Health Care in Canada, 2002)IV, the FirstMinisters’ Accord (Canadian IntergovernmentalConference Secretariat, 2003)IV, and the Academy ofCanadian Executive Nurses’ Leadership Paper (Ferguson-Paré et al., 2002)IV have identified that increased atten-tion to leadership and human resource development inhealth care is needed now.

Professional staff in LTC settings can become better lead-ers with appropriate preparation and educational sup-port; and attention to the quality of their work life(McGilton et al., 2004).IV


LTC homes should have a process in place thatensures adherence to the ethical and legislative rightsof the older resident. [D]

The interdisciplinary team should encourage and facilitateelderly people to understand who is their SubstituteDecision Maker (SDM) in the hierarchy of SDMs while stillmentally capable. The SDM is enacted when a person isdeemed mentally incapable. At this point the SDM hierar-chy is consulted to see who has the authority to make deci-sions on behalf of the patient, unless a Power of Attorney(POA) has already been appointed. When discussing issuesof decision making with patient and clients, help them tounderstand who would be consulted to make decisions ifthey were no longer able to decide on their own, accordingto the SDM hierarchy. If they want to appoint someonewho is not their first SDM according to the hierarchy tomake their health decisions, then a formal POA should beappointed. For example, in Ontario the current hierarchy ofSDMs is as follows:• Guardian of the person• Attorney in a Power of Attorney for Personal Care• Representative as appointed by the Consent and

Capacity Board


• Spouse or Partner• Custodial Parent or child• Parent with right of access• Brother or Sister• Any other relative• Public Guardian and Trustee

If a patient has a spouse but would like their child to actas the decision maker, in this case a POA should be cre-ated. This is also the case if there are multiple childrenor siblings who would be eligible to act as an SDM butthe patient would like to specify a particular child or sib-ling to make decisions on their behalf.

Ethical dilemmas emerge from a variety of issues withinLTC settings and they need to be debated and resolvedfrequently. It is important for practitioners to know andunderstand their provincial law, as it is provincial lawthat helps to protect, promote and support seniors’rights. Additionally, the United Nations Declaration ofthe Rights of Older Persons (http://www.un.org/esa/socdev/iyop/iyop-pop.htm) provides a framework forLTC homes to assess their progress in protecting and pro-moting the rights of older adults. It is most important,however, for practitioners to know and understand thelaw in the province where they practice, as it is provinciallaw that helps to protect, promote and support seniors’rights.


LTC homes should ensure adequate planning, alloca-tion of required resources and organizational andadministrative support for the implementation ofbest practice guidelines. [D]

LTC homes should monitor and evaluate the imple-mentation of best practice recommendations. [D]

Best practice guidelines can be successfully implementedonly with adequate planning, the allocation of requiredresources, and organizational and administrative sup-port. Organizations’ implementation plans shouldinclude:• Assessment of organizational readiness and barriers

to education; • Involvement of all members who will support the

process;• Dedication of a qualified individual to provide lead-

ership for the education and implementationprocess;

• Ongoing opportunities for discussion and educationto reinforce rationale for best practice; and

• Opportunities for reflection on individual and orga-nizational experience in implementing the guide-lines.

Organizations implementing recommendations for bestpractice are advised to consider the means by which theimplementation and its impact will be monitored andevaluated. Considerations would include:• Having dedicated staff provide clinical expertise and

leadership with good interpersonal skills, facilitationand project management skills;

• Establishing a steering committee of key stakehold-ers committed to leading the initiative with an estab-lished work plan for tracking activities,responsibilities and timelines;

• Providing educational sessions and ongoing supportfor implementation; and

• Organizational/administrative support to facilitatethe implementation and evaluation.


Caring for residents in LTC homes with mental healthproblems is often challenging. Concern about the quali-ty of care around the globe led to the recent formation ofan International Psychogeriatric Association (IPA) TaskForce on Mental Health Services in Residential CareHomes (http://www.ipa-online.org). Early discussionssuggest that similar issues are relevant in almost all coun-tries. These issues include inadequate staffing levels, lackof staff training regarding mental health issues, agingand poorly designed LTC homes, failure to identify andassess residents in a timely fashion, inappropriate use ofpsychotropic medications, limited availability of mentalhealth consultants, etc.

Although we share these issues in Canada, there aremodel LTC homes which offer excellent care and in someregions first rate mental health services. Different modelsof service are applied but there is some evidence that liai-son-style services (e.g., multidisciplinary and includingeducation) may be more effective than the traditionalmedical consultation model (Draper, 2000). There havebeen a number of innovative educational programs

including the PIECES Program (http://www.piecescana-da.com/pc-on.html) and the funding of PsychogeriatricResource Consultants in Ontario.

We hope that these Guidelines will prove to be useful tofrontline staff, consultants, administrators, accreditationbodies and others in the service of the residents we carefor, as well as for their families. We realize that it may bedifficult to implement all of the recommendations giventhe challenges described in this guideline document, butwe hope that each facility will strive to adopt as many aspossible.

We view this as a dynamic document and plan to period-ically update the recommendations as new develop-ments occur. Updates will be posted on the CCSMHwebsite (www.ccsmh.ca). We need your feedback regard-ing how to improve the document so please fill out thefeedback survey on the CCSMH website or contact usdirectly. We are also planning a national survey of LTChomes to obtain feedback on the implementation of theGuidelines.

Part 7: Final Thoughts and Future Directions


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Appendix A: Guideline Development Process

Approval forGuideline Projectfrom Pop. Health,

Fund, Public HealthAgency of Canada

Guideline TopicsFormalized

Determine & FormalizeCo-Leads for each group

Determine & Formalize Group Members and Consultants• Determined criteria for selection• Gathered Names and Contacted individuals• Formalized membership

Phase 1: Group Administration & Preparation for Draft Documents (April - June 2005)

Meetings withCo-Leads &Individual

Workgroups

• Terms of Reference• Guiding Principles• Scope of Guidelines

Comprehensiveliterature and

guideline review

• Creation of GuidelineFramework Template

• Identification of guideline& literature review toolsand grading of evidence

Phase 11: Creation of Draft Guideline Documents (May - Sept. 2005)

Meetings withCo-Leads &Workgroups

Shortlist,Review & Rateliterature and

guidelines

Summarizeevidence, gaps &

recommendations

Create draftguideline

documents

Review andrevise draftdocuments

Phase III: Dissemination & ConsultationStage 1: To guideline group members (May - Dec.2005)Stage 2: CCSMH Best Practices Conference Workshop Participants (Sept. 2005)Stage 3: Consultants & Additional Stakeholders (Oct. 2005 - Jan. 2006)

Phase IV: Revision to Draft of GuidelineDocuments (Oct. 2005 - Jan. 2006)

Achieving consensuswithin guideline

groups on content &recommendations

Finalrevisions to

draftdocuments

Phase V:Completion ofFinal Guideline

Document(Jan. 2006)

Feedback fromexternal stake-

holdersreviewed

Phase VI:Dissemination& Evaluation(Mar. 2006)


Avorn and Gurwitz (1995) outlined some basic questionsthat should be asked prior to the prescribing of any drugin LTC settings. These questions are listed in Table 1.

Table 1: Questions to be asked in evaluating anydrug use in a nursing home

1. What is the target problem being treated? (Can wealso identify the goal of therapy as well?)

2. Is the drug necessary?

3. Are nonpharmacologic therapies available?

4. Is this the lowest practical dose?

5. Could discontinuing therapy with a medicinehelp to reduce symptoms?

6. Does this drug have adverse effects that are morelikely to occur in an older patient?

7. Is this the most cost-effective choice?

8. By what criteria, and at what time, will the effectsof therapy be assessed?

Studies have shown that there has frequently been a fail-ure to document reasons for prescribing medications inLTC settings. It is important to describe and documentthe target problem being treated, clearly identify treat-ment goals, to consider alternatives to medications, toreview potential adverse effects, interactions, and mostimportantly, to determine by what criteria, and when,the effects of therapy will be reassessed. Beers and col-leagues (1991) convened a panel of national experts inthe United States in an attempt to reach a consensus ondefining inappropriate medication use in the nursinghome. Using these criteria, they reported that more than40% of residents had at least one inappropriate prescrip-tion in a group of California nursing homes.

Most studies suggest that between 50% and 75% of nurs-ing home residents have at least one prescription for apsychotropic medication. The patterns and rates of use ofthese medications vary widely from institution to institu-tion and from country to country. Snowdon (1993)notes that factors which might explain these variationsinclude differences in the prevalence and severity of dis-orders, levels of physical disability, prescribing habits ofphysicians, involvement by pharmacists, number of

untrained staff, size and design of institutions, fundingand type of institutions, socio-economic background ofthe residents, and policies regarding admissions.Concerns about the use of psychotropic medicationshave included the lack of a documented diagnosis, physi-cian characteristics (rather than those of patients) pre-dicting drug dosage, mental health consultation beingrarely available for LTC residents and the high risk ofcomplications, such as falls, fractures and movement dis-orders. Particular concerns have been raised with regardto the possible overuse of antipsychotic (neuroleptic)drugs and benzodiazepines.

Before prescribing any psychotropic medication it isimportant to rule out any acute medical conditions (suchas infections), and consider the differential diagnosisincluding medication treatment and management ofcoexisting chronic medical conditions that may be con-tributing to the changes in mood or behaviour. It isimportant to be aware of the altered pharmacokineticsand pharmacodynamics of medications in the olderadult.

The American Society of Consultant Pharmacists (ASCP)has developed “Guidelines for the Use ofPsychotherapeutic Medications in Older Adults” (1995).The eight guidelines are as follows:

1. Older adults should be screened for presence of affec-tive, cognitive and other psychiatric disorders.

2. Older adults who exhibit symptoms of psychiatric dis-orders should be thoroughly assessed by a qualifiedhealth care professional.

3. Behavioural symptoms in older adults should beobjectively and quantitatively monitored by caregiversor facility staff and documented on an ongoing basis.When possible, psychiatric symptoms should also bemonitored in this fashion.

4. If the behaviours do not present an immediate seriousthreat to the patient or others, the initial approach tomanagement of behavioural symptoms in olderadults should focus on environmental modifications,behavioural interventions, psychotherapy or othernonpharmacologic interventions.

5. When medications are indicated, select an appropriatepsychotherapeutic agent, considering effectiveness ofthe medication and risk of side effects.

6. Begin medication at the lowest appropriate dosageand increase the dose gradually.

7. Monitor the patient for therapeutic response from themedication and for adverse drug reactions.

8. The psychotherapeutic medication regimen should beroutinely re-evaluated for the need for continued useof medication, dosage adjustments or a change inmedication.

Appendix B. General Principles for Pharmacological Intervention